Perfusion imaging-guided risk stratification and endovascular decision-making in low-NIHSS large-vessel occlusion stroke: a systematic review and exploratory meta-analysis
In brief
Perfusion scans flag low-NIHSS stroke patients six times more likely to worsen
In patients with large-vessel occlusion who present with low NIHSS scores, larger Tmax or perfusion lesion volumes identified a high-risk tissue phenotype that was about six times more likely to experience early neurological deterioration and roughly nine times more likely to have poor functional outcome. Current evidence does not yet show that using these scans to decide on endovascular therapy improves results, so randomized trials are needed.
- Journal
- Journal of neurology (Q1)
- Published
- 26 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Changya Liu, Tao Hu, Xinxin Wu, Wenchao Chu, Xuebin Hu
- PMID
- 42645435
- DOI
- 10.1007/s00415-026-14075-7
Why clinicians should know about it
- Picked for Radiology, Radiation Oncology, Nuclear Medicine, Medical Physics and Imaging (top studies of the week, 30 August 2026): Perfusion imaging risk stratification in low‑NIHSS LVO stroke
Abstract
BACKGROUND: Patients with acute ischemic stroke due to large-vessel occlusion (LVO) may present with low National Institutes of Health Stroke Scale (NIHSS) scores, creating uncertainty regarding the need for endovascular therapy. Perfusion imaging may help identify patients at high risk for early neurological deterioration (END), but its clinical utility in this population remains unclear. METHODS: We performed a systematic review and exploratory meta-analysis of studies evaluating perfusion or hemodynamic imaging in adults with low-NIHSS LVO stroke. PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to June 2026. Eligible studies reported associations between perfusion imaging markers and END or functional outcome, or evaluated imaging-informed endovascular decision-making. Random-effects models were used for exploratory pooled analyses. Risk of bias was assessed using QUIPS and ROBINS-I-informed domains, and certainty of evidence was evaluated using GRADE. RESULTS: The search identified 1698 records, of which 1372 remained after removal of duplicates. The evidence base included perfusion risk-stratification studies, endovascular decision-making studies, background reviews and meta-analyses, and ongoing trial protocols. Larger Tmax-defined hypoperfusion volumes, larger perfusion lesion volumes, and impaired hemodynamic reserve were associated with early neurological deterioration or poor functional outcome. In three studies eligible for exploratory pooling, a high-risk perfusion phenotype was associated with early neurological deterioration or deterioration of ischemic origin (pooled odds ratio, 6.55; 95% confidence interval, 1.65-25.99; I2≈78%). Two studies suggested an association with poor functional outcome (pooled odds ratio, 9.24; 95% confidence interval, 1.99-42.99; I2≈66%). Evidence regarding perfusion-guided endovascular therapy was heterogeneous and observational. CONCLUSIONS: In low-NIHSS LVO stroke, perfusion and hemodynamic imaging identifies a high-risk tissue-at-risk phenotype associated with neurological deterioration and poor outcome. However, evidence supporting perfusion-guided endovascular therapy remains uncertain. Randomized trials are required to define whether imaging-based selection improves outcomes in this population.
Abstract as published, via PubMed.
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