Uncovering the Late Window: The Role of Advanced Imaging (CT Perfusion and MRI) in Improving Ischemic Stroke Outcomes and Patient Selection; A Systematic Review and Meta-analysis
Ahlam Almuabdi1, Nada Alguizzani2, Taif Alharthi3, Alhanouf Alasmari4, Rayan AlGhanami5, Abdulaziz Alharbi6, Hussain Alyami7, Amr Mouminah8
1University of Jeddah, 2King Faisal University, 3Taif university, 4King Khalid University, 5King Saud University, 6Qassim University, 7King Khaled Hospital, 8King Abdullah medical complex jeddah
Objective:
This systematic review and meta-analysis sought to evaluate the effects of advanced imaging (MRI and CT perfusion) on EVT selection for patients with ischemic stroke who presented during the late window.
Background:
Acute ischemic stroke due to large vessel occlusion is a major global cause of death and disability. Advanced imaging modalities, such as MRI (Magnetic Resonance Imaging) and Computed Tomography Perfusion (CTP), have shown potential in guiding EVT decisions in the late window. Still, conflicting data exists on their efficacy and benefits.
Design/Methods:
In November 2024, a literature search was conducted through PubMed, Medline, Web of Science, and Ovid without regard to language or publication year. Studies evaluating the impact of advanced imaging, whether in comparison with basic imaging (non-contrast computed tomography (NCCT) ± computed tomography angiography (CTA)) or intercomparison between MRI and CTP for patients with large vessel occlusion (LVO) undergoing endovascular thrombectomy, were included. The primary outcome was functional independence at 90 days. Procedural safety, hemorrhagic transformation, and mortality were the secondary outcomes.
Results:
Eleven studies with 12,547 patients were included in our analysis. Patients who were selected by basic imaging had higher functional independence than those who had advanced imaging. There was no statistically significant difference between the diffusion-weighted imaging (DWI) on MRI and CT perfusion (CTP). The risks of any cerebral hemorrhage did not significantly differ between advanced and basic imaging for secondary outcomes. In contrast to basic imaging, advanced imaging was linked to lower risks of death. Unfortunately, these effects were not robust after sensitivity analysis.
Conclusions:
The mortality benefit of advanced imaging is still unclear, despite basic imaging showing a slight edge in functional results. Further study is necessary to define the function of advanced imaging in stroke care as well as to determine the patients who may benefit the most from these techniques.
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