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Research ArticleNEUROVASCULAR/STROKE IMAGING

A Comparative Study of CT Perfusion Postprocessing Tools in Medium/Distal Vessel Occlusion Stroke

Helene Corbaz, Nikolaos Ntoulias, Alex Brehm, Julia Wolleb, Philippe Claude Cattin, Florentin Bieder, Victor Schulze-Zachau and Marios-Nikos Psychogios
American Journal of Neuroradiology April 2025, DOI: https://doi.org/10.3174/ajnr.A8616
Helene Corbaz
aFrom the Department of Biomedical Engineering (H.C., J.W., P.C.C., F.B.), University Basel, Basel, Switzerland
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Nikolaos Ntoulias
bDepartment of Diagnostic & Interventional Neuroradiology (N.N., A.B., V.S.-Z., M.-N.P.), Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
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Alex Brehm
bDepartment of Diagnostic & Interventional Neuroradiology (N.N., A.B., V.S.-Z., M.-N.P.), Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
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  • ORCID record for Alex Brehm
Julia Wolleb
aFrom the Department of Biomedical Engineering (H.C., J.W., P.C.C., F.B.), University Basel, Basel, Switzerland
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Philippe Claude Cattin
aFrom the Department of Biomedical Engineering (H.C., J.W., P.C.C., F.B.), University Basel, Basel, Switzerland
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Florentin Bieder
aFrom the Department of Biomedical Engineering (H.C., J.W., P.C.C., F.B.), University Basel, Basel, Switzerland
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Victor Schulze-Zachau
bDepartment of Diagnostic & Interventional Neuroradiology (N.N., A.B., V.S.-Z., M.-N.P.), Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
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Marios-Nikos Psychogios
bDepartment of Diagnostic & Interventional Neuroradiology (N.N., A.B., V.S.-Z., M.-N.P.), Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
cClinical Research Department(M.-N.P.), University Basel, Basel, Switzerland
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  • FIG 1.
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    FIG 1.

    Patient flow chart. *The full-text search was conducted in the local PACS and included the descriptors “acute stroke,” “cerebrovascular insult,” and “National Institutes of Health Stroke Scale” as well as corresponding abbreviations.

  • FIG 2.
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    FIG 2.

    Study workflow.

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    FIG 3.

    Classification scheme.

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    FIG 4.

    Examples of different categories of agreement or disagreement. Figure shows Tmax maps for semiautomated (upper row) and automated postprocessing. A, Agreement. B, Agreement with outliers. Please note contralateral areas of Tmax > 4 seconds indicated in blue in the RapidAI map. C, Tmax > 4 seconds overestimation. Please note how the Tmax >4 seconds lesion of RapidAI extends beyond the lesion of perfusion delay in the Syngo.via Tmax map. D, No Tmax > 6 seconds lesion. E, Volume mismatch. F, Color reference for perfusion maps derived from Syngo.via. G, Color reference for perfusion maps derived from RapidAI.

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    FIG 5.

    Patterns of agreement and disagreement between semiautomated and automated postprocessing.

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    FIG 6.

    Bland-Altman plots for the comparison of mismatch estimates of semiautomated and automated postprocessing. Mismatch volume derived from semiautomated postprocessing (mL) as compared with mismatch volume derived from automated postprocessing (mL). A, In the upper graphic, automated postprocessing mismatch volume was defined as volume of Tmax >4 seconds – volume of CBF <30%. B, In the lower graphic, automated postprocessing mismatch volume was defined as volume of Tmax > 6 seconds – volume of CBF <30%. In both graphics, semiautomated postprocessing mismatch volume was defined as volume of Tmax lesion – volume of CBV lesion. For both comparisons, the discrepancy of mismatch volume was larger for patients with larger average volume of the perfusion lesion. SD indicates standard deviation.

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    Table 1:

    Patient baseline characteristics

    All Patients (n = 49)
    Age (years, median [IQR])76 (15)
    Sex (male patients)33 (67.3%)
    Median NIHSS at admission (IQR)6 (5)
    • Note:—One patient experienced 2 distinct MDVO strokes with a time lag of several months and CTP data sets from both events were included.

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    Table 2:

    Patient baseline characteristics

    Occlusion LocationAll Data Sets (n = 50)
    M222 (44%)
    M318 (36%)
    M42 (4%)
    A10
    A20
    A31 (2%)
    P10
    P26 (12%)
    P31 (2%)
    • Note:—One patient experienced 2 distinct MDVO strokes with a time lag of several months and CTP data sets from both events were included.

    • View popup
    Table 3:

    Distribution of the perfusion lesion volumes

    Median Volume (mL)IQRRange
    Tissue at riska42.833.82–161.8
    Tmax > 4 secondsb67.467.74.2–295.4
    Tmax > 6 secondsb25.421.40–96
    Infarct corea7.325.20–56.8
    CBF <30%b2.89.00–49.1
    Tmax > 10 secondsb7.417.80–63.7
    • Note:—Volumes were estimated by multiplying the computed volume with pixel size.

    • ↵a Results of semiautomated postprocessing.

    • ↵b Results of automated postprocessing.

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    Table 4:

    Median of the DS, HD, and the RVD for the different comparisons


    Median DSMedian HD [mm]Median RVD
    Tissue at riska/Tmax > 6 secondsb0.5942.310.79
    Tissue at riska/Tmax > 4 secondsb0.56105.02−0.30
    Infarct corea/CBF <30%b0.0917.381.40
    Infarct corea/Tmax > 10 secondsb0.3959.662.28
    • ↵a Results of semiautomated postprocessing.

    • ↵b Results of automated postprocessing.

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Cite this article
Helene Corbaz, Nikolaos Ntoulias, Alex Brehm, Julia Wolleb, Philippe Claude Cattin, Florentin Bieder, Victor Schulze-Zachau, Marios-Nikos Psychogios
A Comparative Study of CT Perfusion Postprocessing Tools in Medium/Distal Vessel Occlusion Stroke
American Journal of Neuroradiology Apr 2025, DOI: 10.3174/ajnr.A8616

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CTP Postprocessing Tools in MDVO Stroke
Helene Corbaz, Nikolaos Ntoulias, Alex Brehm, Julia Wolleb, Philippe Claude Cattin, Florentin Bieder, Victor Schulze-Zachau, Marios-Nikos Psychogios
American Journal of Neuroradiology Apr 2025, DOI: 10.3174/ajnr.A8616
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