Patients With Ischemic Core ≥70 ml Within 6 h of Symptom Onset May Still Benefit From Endovascular Treatment

Chen, Zhicai; Zhang, Ruiting; Zhou, Ying; Gong, Xiaoxian; Zhang, Meixia; Shi, Feina; Yu, Xinfeng; Lou, Min

doi:10.3389/fneur.2018.00933

Cited by 23 publications

(23 citation statements)

References 27 publications

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“…Amongst 622 studies screened for inclusion and two records yielded from other sources between 2015 and June 2020, a total of 10 records 3,6,8,[15][16][17][18][19][20][21] with 954 patients with baseline large ischemic volumes were included in our review. See flowchart of studies selection in Figure 1.…”

Section: Literature Review and Study Selectionmentioning

(Expert classified)

“…Five studies (71.5%) were from a single center, and six (85.7%) reported a prospective enrolment. Amongst the included studies, six 3,8,16,[19][20][21] totalizing 682 patients had control groups treated with BMT alone, allowing to compare 332 patients who received MT to 350 who received BMT only. Four studies 3,6,15,18 used only MRI, two 8,20 over 90% of MRI and were merged with the MRI group.…”

Section: Literature Review and Study Selectionmentioning

confidence: 99%

“…Four studies 3,6,15,18 used only MRI, two 8,20 over 90% of MRI and were merged with the MRI group. Three 16,17,19 used only CTP and one 21 over 90% of CTP and was merged with the CTP group.…”

Section: Literature Review and Study Selectionmentioning

confidence: 99%

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Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis

Kerleroux

Janot

Hak³

et al. 2021

J Stroke

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The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.

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Section: Literature Review and Study Selectionmentioning

(Expert classified)

Section: Literature Review and Study Selectionmentioning

confidence: 99%

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Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis

Kerleroux

Janot

Hak³

et al. 2021

J Stroke

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“…Chen et al performed a retrospective review and stated that endovascular therapy performed within 6 hours of onset achieved higher reperfusion and recanalization rates compared to IV-tPA. 62 Gligen et al demonstrated similar results in younger patients with large MRI-DWI lesions. 63 Kaesmacher et al were able to show that mechanical thrombectomy in patients with Alberta Stroke Program Early CT Score of 0 to 5 were able to have successful reperfusion, with no increase in the rate of sICH.…”

Section: Treatment Of Large Core Strokesmentioning

confidence: 70%

A New Era of Extended Time Window Acute Stroke Interventions Guided by Imaging

Rehani

Ammanuel

Zhang

et al. 2019

The Neurohospitalist

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Ischemic stroke is one of the most debilitating and deadliest conditions worldwide. Intravenous t-PA is the current standard treatment within 4 hours after onset of symptoms. Recent randomized controlled trials have demonstrated the efficacy of neurointerventional intra-arterial treatment in acute ischemic stroke. About 20% of acute ischemic stroke are classified as wake-up strokes, which falls out of the conventional treatment time window. New evidence suggests that some patients with longer time from symptom onset (up to 24 hours) may benefit from thrombectomy, probably in part due to variations in collateral circulation among individual patients. Advanced imaging can play a crucial role in identifying patients who could benefit from endovascular intervention presenting within extended treatment time windows. In this article, we review the advanced imaging algorithm for ischemic stroke workup in the multiple studies published to date and summarize the results of the clinical trials for late ischemic stroke that can be clinically useful.

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“…However, this concept came from the studies conducted in patients receiving intravenous thrombolysis whereby a higher rate of symptomatic intracerebral hemorrhage and poorer outcomes can be attributable to malignant profile [1]. Recently, there has been some evidence that patients who present within 6 h with a core volume ≥70 mL may still benefit from EVT, which was potentially related to high reperfusion rates observed in these studies [3]. The SELECT study suggests that there are potential benefits for patients with large cores up to 24 h from the time last known to be well, who were selected based on an Alberta Stroke Program Early CT Score (ASPECTS) of less than 6, or a volume with a relative cerebral blood flow <30% of ≥50 cm 3 on CT perfusion scanning [4].…”

Section: Introductionmentioning

confidence: 99%

A Challenging Case: Endovascular Treatment in a Patient with Large Ischemic Core and Dramatic Recovery

Nguyen¹,

Dang

Phan

et al. 2020

Case Rep Neurol

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Uncertainty exists over the efficacy and safety of endovascular treatment in patients with large ischemic cores in anterior circulation. Several trials have shown some potential benefits in selected patients despite their late presentation. In particular, perfusion imaging modalities equipped with automatic software has been proven useful in identifying patients with large ischemic cores that are at risk of infarct core expansion, meaning that this specific patient group could still benefit from reperfusion treatment. We reported a case of late-presenting and progressing acute ischemic stroke who was selected by perfusion imaging with RAPID software and successfully underwent endovascular thrombectomy. On admission, her National Institutes of Health Stroke Scale (NIHSS) score was 7. Computed tomography angiography showed complete occlusion of the proximal right middle cerebral artery. Subsequent advanced perfusion imaging with automatic software showed that the ischemic core was 88 mL, T<sub>max</sub> >6 s volume was 131 mL, and mismatch volume was 43 mL. She was rapidly transferred to the Cath lab for thrombectomy with a stent retriever. Her NIHSS score was 15 before the endovascular procedure. She had a dramatic recovery with an NIHSS score of 4 at 24-h after the procedure. She was discharged on day 9 with a modified Rankin Score of 1. Our findings suggest that endovascular treatment can be beneficial to the patients, particularly younger ones, with large ischemic cores with the aid of perfusion imaging.

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Patients With Ischemic Core ≥70 ml Within 6 h of Symptom Onset May Still Benefit From Endovascular Treatment

Cited by 23 publications

References 27 publications

Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis

Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis

A New Era of Extended Time Window Acute Stroke Interventions Guided by Imaging

A Challenging Case: Endovascular Treatment in a Patient with Large Ischemic Core and Dramatic Recovery

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