Perfusion Parameters to Identify Acute Steno-occlusive Carotid Artery Disease Due to Atherosclerosis Prior to Endovascular Therapy.

BACKGROUND AND PURPOSE: Perfusion imaging is commonly utilized to assess collateral status in patients with acute ischemic stroke due to anterior large-vessel occlusion. However, its potential role in identifying the etiology of extracranial ICA lesions before endovascular therapy (EVT) remains underexplored. We aimed to evaluate the utility of perfusion imaging parameters-particularly the hypoperfusion intensity ratio (HIR)-in detecting extracranial ICA steno-occlusion caused by atherosclerotic disease before EVT.

MATERIALS AND

METHODS

We conducted a retrospective cohort study of patients with consecutive EVT stroke in our institutional registry from January 2019 to December 2022 who underwent CT perfusion imaging and had ≥70% extracranial ICA stenosis. Patients were categorized into those with atherosclerotic and nonatherosclerotic ICA based on clinical and radiologic characteristics. Perfusion parameters, including CBF, CBV, time-to-maximum (Tmax), and Tmax mismatch ratios, were compared between groups. Multivariable logistic regression was performed to identify independent predictors of atherosclerotic disease.

RESULTS

Of the 622 patients who underwent EVT, 78 met the inclusion criteria (median age 68 [60-76], 39.7% women, median NIHSS 15 [10-18]), and 53 (67.9%) had atherosclerotic ICA lesions. Compared with nonatherosclerotic cases, these patients had significantly lower median volumes of CBF <20% (0 versus 4 mL), lower HIR (0.27 versus 0.47, P < .01), and reduced Tmax mismatch ratios across several thresholds. In multivariable analysis, lower HIR (adjusted OR 0.01; 95% CI: 0.00-0,16) and several Tmax mismatch ratios, including >10 seconds/>8 seconds (adjusted OR 0.05; 95% CI: 0.00-0.53), >10 seconds/>4 seconds (adjusted OR 0.01; 95% CI: 0.00-0.26), >8 seconds/>6 seconds (adjusted OR 0.04; 95% CI: 0.00-0.58), and >8 seconds/>4 seconds (adjusted OR 0.04; 95% CI: 0.00-0.86), were independently associated with atherosclerotic ICA lesions.

CONCLUSIONS

HIR and Tmax mismatch ratios (>10 seconds/>8 seconds, >10 seconds/4 seconds, >8 seconds/6 seconds, >8 seconds/4 seconds) were associated with acute steno-occlusive ICA due to atherosclerotic disease before EVT. Early identification of the underlying etiology may facilitate a more tailored cervical approach during endovascular treatment.