Baseline ASPECTS and hypoperfusion intensity ratio influence the impact of first pass reperfusion on functional outcomes

Abstract

BackgroundFirst pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.MethodsA prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c–3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR <0.3 versus ≥0.3. Univariable and multivariable analyses were performed to establish the predictors of 90-day functional independence (modified Rankin Scale (mRS) ≤2) in each subgroup.ResultsA total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR <0.3 (62.9% vs 52.8%, adjusted OR 1.524; 95% CI 0.592 to 3.920, p=0.38).ConclusionsThe impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

Low Hypoperfusion Intensity Ratio Is Associated with a Favorable Outcome Even in Large Ischemic Core and Delayed Recanalization Time

“…In previous studies, a cut-off point of the HIR to predict a favorable functional outcome were not calculated; the cut-off points of the HIR for the collateral status and infarct growth were calculated as 0.40 and 0.50, respectively [ 7 , 8 , 9 ]. Most studies merely dichotomized the HIR by its median value, with a range of 0.30–0.45, to evaluate the association of the dichotomized HIR value with the fluid-attenuated inversion recovery (FLAIR) hyperintense vessel sign, infarct growth, or first-pass effect in mechanical thrombectomy [ 7 , 19 , 20 , 21 ]. In these studies, a median HIR value of <0.40 was significantly associated with a positive outcome [ 7 ].…”

Factors Influencing Recanalization After Mechanical Thrombectomy With First-Pass Effect for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

“…Thrombectomy with first pass effect (FPE), an emerging new metric, is strongly correlated with improved functional outcomes (7)(8)(9)(10). Thrombectomy with FPE may have many advantages such as less vessel wall injury, lower risk of clot fragments, and decreased time to reperfusion (8,11). Also, FPE is associated with better outcomes than MPE after achieving successful or complete recanalization (12).…”

“…Thus, identifying factors influencing FPE could help clinicians and interventionalists maximize the benefit of MT through suitable patient selection and pre-interventional risk modification. There are many studies seeking to explore this phenomenon, but with inconsistent results (7,8,11,(13)(14)(15)(16)(17)(18)(19)(20). For example, balloon guide catheters (BGC) and non-internal carotid artery (ICA) terminus occlusion were correlated with FPE in the study of Zaidat et al (7), but factors such as older age, a lower systolic blood pressure, and conscious sedation were not (17).…”

Carotid Artery Perivascular Adipose Tissue Density Relates to Recanalization and Clinical Outcome After Mechanical Thrombectomy

“…The modified Thrombolysis in Cerebral Infarction (mTICI) score was used to assess revascularization at the end of the procedure. A mTICI score of 2b-3 was considered indicative of successful recanalization ( Mohammaden et al, 2021 ).…”

“…Stroke etiology was determined using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria: (1) large artery atherosclerosis (LAA); (2) small vessel occlusion (SVO); (3) cardioembolism (CE); and (4) other determined or undetermined etiologies ( Adams et al, 1993 ). Neurological severity was measured with the National Institute of Health Stroke Score (NIHSS) ( Adams et al, 1999 ), and the Alberta Stroke Programme Early CT score (ASPECTS) was determined as previously reported ( Mohammaden et al, 2021 ). Symptomatic intracranial hemorrhage (sICH) was defined according to the European Cooperative Acute Stroke Study (ECASS) III criteria ( Hacke et al, 2008 ).…”