title: Admission CT perfusion may overestimate initial infarct core: the ghost infarct core concept.
abstract: BACKGROUND
  Identifying infarct core on admission is essential to establish the amount of salvageable tissue and indicate reperfusion therapies. Infarct core is established on CT perfusion (CTP) as the severely hypoperfused area, however the correlation between hypoperfusion and infarct core may be time-dependent as it is not a direct indicator of tissue damage. This study aims to characterize those cases in which the admission core lesion on CTP does not reflect an infarct on follow-up imaging.
  
  
  METHODS
  We studied patients with cerebral large vessel occlusion who underwent CTP on admission but received endovascular thrombectomy based on a non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS) >6. Admission infarct core was measured on initial cerebral blood volume (CBV) CTP and final infarct on follow-up CT. We defined ghost infarct core (GIC) as initial core minus final infarct >10 mL.
  
  
  RESULTS
  79 patients were studied. Median National Institutes of Health Stroke Scale (NIHSS) score was 17 (11-20), median time from symptoms to CTP was 215 (87-327) min, and recanalization rate (TICI 2b-3) was 77%. Thirty patients (38%) presented with a GIC >10 mL. GIC >10 mL was associated with recanalization (TICI 2b-3: 90% vs 68%; p=0.026), admission glycemia (<185 mg/dL: 42% vs 0%; p=0.028), and time to CTP (<185 min: 51% vs >185 min: 26%; p=0.033). An adjusted logistic regression model identified time from symptom to CTP imaging <185 min as the only predictor of GIC >10 mL (OR 2.89, 95% CI 1.04 to 8.09). At 24 hours, clinical improvement was more frequent in patients with GIC >10 mL (66.6% vs 39%; p=0.017).
  
  
  CONCLUSIONS
  CT perfusion may overestimate final infarct core, especially in the early time window. Selecting patients for reperfusion therapies based on the CTP mismatch concept may deny treatment to patients who might still benefit from reperfusion.
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Sandra
authors: S
authors: Boned
authors: Università di Ferrara, Sezione di Clinica Neurologica, Ferrara, Italia.
authors: Marina
authors: M
authors: Padroni
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Marta
authors: M
authors: Rubiera
authors: Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain.
authors: Alejandro
authors: A
authors: Tomasello
authors: Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain.
authors: Pilar
authors: P
authors: Coscojuela
authors: Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain.
authors: Nicolás
authors: N
authors: Romero
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Marián
authors: M
authors: Muchada
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: David
authors: D
authors: Rodríguez-Luna
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Alan
authors: A
authors: Flores
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Noelia
authors: N
authors: Rodríguez
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Jesús
authors: J
authors: Juega
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Jorge
authors: J
authors: Pagola
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: José
authors: J
authors: Alvarez-Sabin
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Carlos A
authors: CA
authors: Molina
authors: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.|Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors: Marc
authors: M
authors: Ribó
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000628:therapy; D002544:Cerebral Infarction / Q000000981:diagnostic imaging* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010343:Patient Admission; D055420:Perfusion Imaging / Q000379:methods*; D015424:Reperfusion; D020521:Stroke / Q000000981:diagnostic imaging / Q000628:therapy; D017131:Thrombectomy / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: CT perfusion; Stroke; Thrombectomy