Purpose: Dual-energy CT (DECT) material decomposition techniques may better detect edema within cerebral infarcts than conventional non-contrast CT (NCCT). We determined if Virtual Ischemia Maps (VIM) derived from non-contrast DECT of patients with acute ischemic stroke due to large-vessel occlusion (AIS-LVO) are superior to NCCT for core infarct estimation.

Materials and Methods: Consecutive AIS-LVO patients with baseline non-contrast DECT, CT perfusion (CTP), and DWI-MRI were identified between 9/2018-8/2019 from a prospective database. Patients whose baseline core infarcts were likely to remain stable on follow-up MRI were included, defined as those with excellent post-thrombectomy revascularization or no perfusion mismatch. Core infarct volumes were manually segmented on NCCT, VIM, and DWI, and derived from CTP. Core volume agreement was assessed using Bland-Altman plots and comparison of CT to DWI volume ratios. Three blinded neuroradiologists provided an ASPECTS for VIM and NCCT, which were compared against a consensus DWI-ASPECTS.

Results: Twenty-four patients were included (46% female, 64.315.0 years). Median time from last known normal to CT was 7.5 (IQR 1.5-14.5) hours. Final DWI volume was better approximated by VIM than NCCT (0.680.35 vs. 0.340.35; P<0.001) or CTP (0.450.67; P<0.001). Bland-Altman analyses indicated significantly greater agreement between DWI and VIM than NCCT core volumes (mean bias 0.60 [95%AI 0.39-0.82] vs. 0.20 [95%AI 0.11-0.30]). Pooled VIM- and NCCT-ASPECTS differed significantly (6.42.5 vs. 7.62.0; P<0.001), and VIM was more accurate than NCCT in estimating DWI-ASPECTS (71% vs. 65%).

Conclusion: DECT VIM estimates core infarction in AIS-LVO patients more accurately than NCCT.

Virtual Non-Contrast Dual-Energy CT Reconstructions More Accurately Estimate Core Infarct Volume Over Conventional Non-Contrast CT

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