Intra-Arterial Therapy and Post-Treatment Infarct Volumes

Abstract

Background and Purpose-The goal of reperfusion therapy in acute ischemic stroke is to limit brain infarction. The objective of this study was to investigate whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in post-treatment infarct volume. Methods-The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis onMinimizing CT to Recanalization Times (ESCAPE) trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 315 enrolled subjects (endovascular treatment n=165; control n=150), 314 subject's infarct volumes at 24 to 48 hours on magnetic resonance imaging (n=254) or computed tomography (n=60) were measured. Posttreatment infarct volumes were compared by treatment assignment and recanalization/reperfusion status. Appropriate statistical models were used to assess relationship between baseline clinical and imaging variables, post-treatment infarct volume, and functional status at 90 days (modified Rankin Scale). Results-Median post-treatment infarct volume in all subjects was 21 mL (interquartile range =65 mL), in the intervention arm, 15.5 mL (interquartile range =41.5 mL), and in the control arm, 33.5 mL (interquartile range =84 mL; P<0.01). Baseline National Institute of Health Stroke Scale (P<0.01), site of occlusion (P<0.01), baseline noncontrast computed tomographic scan Alberta Stroke Program Early CT score (ASPECTS) (P<0.01), and recanalization (P<0.01) were independently associated with post-treatment infarct volume, whereas age, sex, treatment type, intravenous alteplase, and time from onset to randomization were not (P>0.05). Post-treatment infarct volume (P<0.01) and delta National Institute of Health Stroke Scale (P<0.01) were independently associated with 90-day modified Rankin Scale, whereas laterality (left versus right) was not. E verything that we think, plan, or do comes from within the human brain. Our language, our arts and culture, the meaning of being human are all products of the human brain. The drugs, devices, and techniques we have developed for acute ischemic stroke therapy are aimed at saving the human brain from death. Clinical trials in ischemic stroke test if these therapies are capable of reducing damage to the brain. Conclusions-TheseAn ability to speak, listen, and understand; to move, walk, or run; to see and interact with the world around us are all examples of brain functions. Clinical trials use ordinal scales like the modified Rankin Scale (mRS), the National Institute of Health Stroke Scale (NIHSS), or the Barthel index to quantify these functions.1-3 Understandably, none of these scales ever capture the entirety of functions and capabilities of the human brain. Therefore, it is important for stroke therapies being tested within clinical trials to also be able to show that they save brain tissue.Using a detailed post hoc analysis of the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minim...

Endovascular Therapy vs. Thrombolysis in Pre-stroke Dependent Patients With Large Vessel Occlusions Within the Anterior Circulation

“…Using the follow-up ASPECTS as a marker of infarct extent, we observed significantly smaller infarct sizes after ET than after IVT in dependent patients. These data corroborate previous findings, albeit mainly in independent patients, in which the final infarct volumes were significantly smaller after ET than after IVT ( 21 , 22 ). Although it has clearly been shown that a reduced final infarct volume only partially mediates the positive effect of ET on clinical outcome ( 21 ), our primary finding of an improved clinical outcome after ET in dependent patients is thus also supported by the imaging data.…”

Predictors of Infarct Growth in Patients with Large Vessel Occlusion Treated with Endovascular Therapy

“…These results are in agreement with those obtained by Man et al ( 19 ) We found that failure of reperfusion resulted in infarct growth of approximately 50 ml. In a comparable analysis, Zaidi and colleagues found a mean infarct volume in the recanalized vs. non-recanalized of 50 vs. 134 ml, respectively ( 20 ), while the ESCAPE study found a difference between the recanalized and non-recanalized of only 20.5 ml ( 21 ). These studies could only compare the final infarct between reperfusers and non-reperfusers not knowing the initial infarct.…”

Regional Contributions to Poststroke Disability in Endovascular Therapy

“…Various post hoc exploratory analyses of the SWIFT PRIME [23] and ESCAPE [24] trials have demonstrated the 24-to 48-h infarct volumes as a strong predictor of 90-day mRS score. However, laterality of the infarction was not observed to be a significant predictor for 90-day clinical outcomes [24].…”