Diagnostic Accuracy of Ischemia and Hemorrhage on Cone-Beam CT Immediately After Endovascular Thrombectomy

BACKGROUND: Detection of ischemia and intracranial hemorrhage (ICH) directly after endovascular thrombectomy (EVT) could enable earlier diagnosis and treatment. We evaluated whether post-EVT Sine Spin cone-beam computed tomography (CBCT) on the Siemens ARTIS Icono biplane system at the end of the procedure can predict ischemia and ICH on subsequent follow-up computed tomography (FUCT) within 48 hours. METHODS: Adult patients undergoing EVT in 2024 with available CBCT and FUCT were included. Two interventional neuroradiologists independently evaluated the CBCT examinations for ischemia, ICH (including Heidelberg classification), and image quality. FUCT, annotated by a neuroradiologist, was used as reference standard. Large ischemia was defined as ischemia involving ≥3 predefined vascular territories. RESULTS: Of 331 patients with EVT, 225 had both CBCT and FUCT, of which 197 (88%) were successfully recanalized. Ischemia was observed in 127 (56%) and ICH in 64 (28%) of the FUCTs. For ICH, sensitivity was 75%/77% (reviewer 1/reviewer 2), specificity 85%/84%, and positive predictive value 67% for both reviewers, negative predictive value 92%/91%, and accuracy 84%/83%. Accuracy for large ischemia (n=24, 11%) was 78%/67%. Sensitivity for correctly located ischemia on CBCT was 48%/73%, with specificity of 87%/60%, positive predictive value of 82%/71%, negative predictive value of 56%/63%, and accuracy of 65%/68%. CBCT was rated overall nondiagnostic in 0%/1% of the cases. For the posterior fossa specifically, 6%/16% of examinations were rated nondiagnostic. CONCLUSIONS: Sine Spin CBCT on the Siemens ARTIS Icono biplane system after EVT showed high accuracy for predicting ICH and large ischemia on FUCT. CBCT may help identify patients needing closer monitoring or early neurosurgical intervention.