Antegrade flow across incomplete vessel occlusions can be distinguished from retrograde collateral flow using 4-dimensional computed tomographic angiography

BACKGROUND AND PURPOSE: In acute stroke patients with intracranial vessel occlusion, angiographic demonstration of antegrade contrast opacification distal to the occlusion site (termed the "clot outline sign") has been associated with higher rates of vessel recanalization. We sought to determine whether antegrade flow can be demonstrated on time-resolved 4-dimensional computed tomographic angiography (4-dimensional CTA), whether it can be distinguished from retrograde collateral flow, and if it can be used to predict early recanalization.

METHODS: Fifty-seven acute stroke patients with intracranial anterior circulation vessel occlusion were retrospectively identified. All patients had received a multimodal computed tomography examination including thin-section 4-dimensional CTA and subsequent digital subtraction angiography as part of an endovascular procedure. Pretreatment 4-dimensional CTA and single-phase CTA were assessed for presence of antegrade contrast opacification distal to the occlusion site. Digital subtraction angiograms were reviewed for preintervention Thrombolysis in Cerebral Infarction grade, presence of the clot outline sign, as well as postintervention Thrombolysis in Cerebral Infarction grade.

RESULTS: On 4-dimensional CTA, evidence of antegrade flow was present in 11 of 57 cases (19.3%). Compared with angiography, 4-dimensional CTA predicted antegrade flow with 100% sensitivity and 97.9% specificity. Single-phase CTA offered 40% sensitivity and 87.2% specificity. Early recanalization occurred in 3 patients (6.5%) after intravenous thrombolysis (n=46); all demonstrated antegrade flow on 4-dimensional CTA.

CONCLUSIONS: Using 4-dimensional CTA, it is possible to noninvasively distinguish antegrade flow across a cerebral artery occlusion from retrograde collateral flow. Presence of antegrade flow on 4-dimensional CTA is associated with an increased chance of early vessel recanalization.