Discrepancy between post-treatment infarct volume and 90-day outcome in the ESCAPE randomized controlled trial

Abstract

Background Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better. Aims We explored factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome. Methods We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24–48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24–48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between “discrepant cases” – those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV – and “non-discrepant cases”. Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome. Results Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement ( p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age ( p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS ( p = 0.007) and post-stroke complications ( p = 0.026). Absence of vascular risk-factors ( p = 0.004), CT-based lentiform nucleus sparing ( p = 0.002), lower 24-hour NIHSS ( p = 0.001), and absence of complications ( p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results. Conclusions Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01778335 .

Developing a Nomogram to Predict the Probability of Subsequent Vascular Events at 6-Month in Chinese Patients with Minor Ischemic Stroke

“… 31 Ganesh et al found that patients with large posttreatment infarct volume (PIV) rarely developed serious adverse events. 32 This result is consistent with our findings. The authors pointed out that, although the PIV was large, the sparing of lentiform nucleus was independently associated with good mRS scores.…”

“…Lentiform involvement may suggest a more proximal M1 segment middle cerebral artery or internal carotid artery involvement and potentially more white matter involvement than infarctions that spare the lentiform nucleus. 32 , 33 Therefore, a more detailed and precise analysis of lesion location can help us clarify the contribution of functional eloquence to stroke outcome.…”

Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial

“…If a small infarct volume is achieved, then outcome will be determined, not by the infarct, but by complications in the follow-up period, meaning that attention to stroke unit care, stroke work-up, and prevention posttreatment will be deterministic in outcome. 11 Furthermore, involvement of certain anatomic structures and the eloquence of the affected brain parenchyma probably play a role in clinical outcome in patients with small infarcts. Those with very large infarcts have so much injury that postprocedural care, while important for compassionate and palliative goals of care, may simply not be substantially important in predicting good outcome.…”

MRI Diffusion‐Weighted Imaging to Measure Infarct Volume: Assessment of Manual Segmentation Variability

“…Second, the pure volumetric measurement does not take into account the impact of the eloquent areas of the brain 39 . The recent study by Ganesh et al demonstrated a better clinical outcome in patients where the lentiform nucleus was spared despite the large ILV 40 . Therefore, future studies focused on evaluation of ILV together with the functional eloquence need to be performed to clarify this association.…”