Computed tomography perfusion parameters predictive of symptomatic intracranial hemorrhage after mechanical thrombectomy in patients with cerebral large vessel occlusion

Abstract

AbstractBackgroundHemorrhagic transformation (HT) after recanalization is a severe complication in patients with a large ischemic core due to cerebral large vessel occlusion. Risk assessment using perfusion imaging to predict hemorrhagic infarction has not been established. Thus, we aimed to investigate the association between perfusion imaging findings and HT in patients with acute cerebral large vessel occlusion who had undergone preoperative perfusion imaging evaluation and mechanical thrombectomy.MethodsWe enrolled consecutive patients who received mechanical thrombectomy (MT) after undergoing perfusion imaging for anterior large vessel occlusion from May 2019 to March 2022. The patients in whom recanalization was not achieved and who experienced procedure-related bleeding were excluded. We investigated the predictors of symptomatic intracranial hemorrhage (sICH) by exploring preoperative perfusion imaging parameters [relative cerebral blood flow, relative cerebral blood volume (rCBV), time of maximum concentration, hypoperfusion index ratio].ResultsAmong the 167 patients (median age 79 years, 47% female) enrolled, 63 (38%) and 14 (8%) patients had any intracranial hemorrhage and sICH (sICH group), respectively. The sICH group had a shorter puncture-recanalization time than the non-sICH group (median [interquartile range (IQR)]; 43 [34–55] vs. 61 [37–88], p = 0.046), whereas the modified Rankin Scale at 90 days showed a worse prognosis (median [IQR]; 5 [5–6] vs 3 [1–4], p<0.01). All perfusion imaging parameters were significantly predicting the sICH group in multiple logistic regression analysis. The value of rCBV was the parameter most strongly associated with sICH in receiver operating characteristic curve analysis (area under the curve = 0.90, 95% confidence interval [0.83–0.98]; cutoff 43 ml; sensitivity, 86 %; specificity, 87%).ConclusionAmong perfusion CT parameters, rCBV is highly associated with sICH after MT for cerebral large vessel occlusion. In patients with low rCBV regions, the indication of mechanical thrombectomy should be carefully considered for postoperative intracranial hemorrhage.Clinical perspectiveOf the various parameters assessed via perfusion CT, the value of rCBV demonstrates a strong correlation with the occurrence of symptomatic intracranial hemorrhage following mechanical thrombectomy for cerebral anterior large vessel occlusion.When treating patients with regions of large low-rCBV, it is important to carefully determine the indication of mechanical due to the potential risk of postoperative intracranial hemorrhage.