CT perfusion stroke lesion threshold calibration between deconvolution algorithms

Structured Abstract Objective CTP is an important diagnostic tool in managing patients with acute ischemic stroke, but challenges persist in the reliability of stroke lesion volumes determined with different software. We investigated a systematic method to calibrate CTP lesion thresholds between deconvolution algorithms using a digital perfusion phantom. Approach The accuracy of one model-independent and two model-based deconvolution algorithms in estimating ground truth cerebral blood flow (CBF) and Tmax in the phantom was quantified. Reference thresholds for ischemic core and penumbra were model-independent CBF6 s, respectively, which is the current clinical standard. The equivalent model-based CBF and Tmax thresholds were determined by comparing linear regressions of phantom ground truth and deconvolution-estimated perfusion between algorithms. Calibrated thresholds were then validated in 63 patients with large vessel stroke by comparing admission CTP ischemic core and <3-hour diffusion-weighted imaging (DWI) lesion volume by Bland-Altman analysis. Agreement in target mismatch (core < 70 ml, penumbra ≥ 15 ml, mismatch ratio ≥ 1.8) determined by the three methods was assessed by Cohen’s kappa (κ) and concordance. Main Results The calibrated thresholds were CBF6 s for both model-based methods. DWI minus CTP lesion mean volume differences (95% limits of agreement) were +16.2 (−30.9 to 63.3) ml, +10.9 (−32.9 to 54.7) ml, and +13.8 (−48.1 to 75.7) ml for model-independent and the two calibrated model-based approaches, respectively. Agreement in mismatch profiles with the two model-based deconvolution methods versus model-independent assessment was κ = 0.87 (95% confidence interval [CI]: 0.72 to 1.00) and κ = 0.86 (95% CI: 0.70 to 1.00), and both achieved 95% concordance. Significance We reported a systematic method of calibrating perfusion thresholds between deconvolution algorithms based on their quantitative accuracy. This may harmonize ischemic lesion volumes determined by different CTP software.