Perfusion Imaging for Endovascular Thrombectomy in Acute Ischemic Stroke Is Associated With Improved Functional Outcomes in the Early and Late Time Windows

Abstract

Background: The impact on clinical outcomes of patient selection using perfusion imaging for endovascular thrombectomy (EVT) in patients with acute ischemic stroke presenting beyond 6 hours from onset remains undetermined in routine clinical practice. Methods: Patients from a national stroke registry that underwent EVT selected with or without perfusion imaging (noncontrast computed tomography/computed tomography angiography) in the early (<6 hours) and late (6–24 hours) time windows, between October 2015 and March 2020, were compared. The primary outcome was the ordinal shift in the modified Rankin Scale score at hospital discharge. Other outcomes included functional independence (modified Rankin Scale score ≤2) and in-hospital mortality, symptomatic intracerebral hemorrhage, successful reperfusion (Thrombolysis in Cerebral Infarction score 2b–3), early neurological deterioration, futile recanalization (modified Rankin Scale score 4–6 despite successful reperfusion) and procedural time metrics. Multivariable analyses were performed, adjusted for age, sex, baseline stroke severity, prestroke disability, intravenous thrombolysis, mode of anesthesia (Model 1) and including EVT technique, balloon guide catheter, and center (Model 2). Results: We included 4249 patients, 3203 in the early window (593 with perfusion versus 2610 without perfusion) and 1046 in the late window (378 with perfusion versus 668 without perfusion). Within the late window, patients with perfusion imaging had a shift towards better functional outcome at discharge compared with those without perfusion imaging (adjusted common odds ratio [OR], 1.45 [95% CI, 1.16–1.83]; P =0.001). There was no significant difference in functional independence (29.3% with perfusion versus 24.8% without; P =0.210) or in the safety outcome measures of symptomatic intracerebral hemorrhage ( P =0.53) and in-hospital mortality (10.6% with perfusion versus 14.3% without; P =0.053). In the early time window, patients with perfusion imaging had significantly improved odds of functional outcome (adjusted common OR, 1.51 [95% CI, 1.28–1.78]; P =0.0001) and functional independence (41.6% versus 33.6%, adjusted OR, 1.31 [95% CI, 1.08–1.59]; P =0.006). Perfusion imaging was associated with lower odds of futile recanalization in both time windows (late: adjusted OR, 0.70 [95% CI, 0.50–0.97]; P =0.034; early: adjusted OR, 0.80 [95% CI, 0.65–0.99]; P =0.047). Conclusions: In this real-world study, acquisition of perfusion imaging for EVT was associated with improvement in functional disability in the early and late time windows compared with nonperfusion neuroimaging. These indirect comparisons should be interpreted with caution while awaiting confirmatory data from prospective randomized trials.

Simplified stroke imaging selection modality for endovascular thrombectomy in the extended time window: systematic review and meta-analysis

“…Compared with non-perfusion neuroimaging, acquisition of CTP for EVT was related to improved functional outcomes in the late time windows. 21 In this meta-analysis, when comparing the more simplified NCCT±CTA imaging selection modality (no-CTP) with the CTP imaging selection modality, the rate of functional independence was similar whether the strict DAWN/DEFUSE 3-like criteria or more inclusive overall criteria were applied. The NCCT±CTA imaging selection modality led to equivalent outcomes to those in patients selected by CTP.…”

“…However, the result of the recent study was inconsistent with previous research. Compared with non-perfusion neuroimaging, acquisition of CTP for EVT was related to improved functional outcomes in the late time windows 21…”

CT perfusion stroke lesion threshold calibration between deconvolution algorithms

“…1 Other guidelines do not discourage CTP in the early time window, 2 and there are studies that suggest its benefit over standard neuroimaging alone. 33,34 Our calibration method nonetheless requires additional validation in patients presenting in the 6 to 24-hour time window.…”

Advances in Futile Reperfusion following Endovascular Treatment in Acute Ischemic Stroke due to Large Vessel Occlusion

“…Low ASPECTS [50] Large infarct volume [51] Insufficient arterial collateral status [52] The delayed PTV [34] Leukoaraiosis [26] Brain atrophy [53] Encephaledema assessed by NWU [54,55] CT selection for MT as compared to MRI [16] NCCT±CTA selection for EVT-eligible patients as compared to NCCT with CT perfusion imaging±CTA [33] Laboratory data High serum glucose [48] High blood NLR [56] Admission systemic inflammatory response index (SIRI) calculated as ANC × AMC/ALC ≥3.8 × 10 9 /L [24] High baseline serum CysC [29] High level of MMP-9, tenascin-C, and thioredoxin [25] Decreased level of post-EVT lipid mediators LXA4 and LXA4/LTB4 ratio [57] Decreased level of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) and gelsolin [25] FR, futile reperfusion; EVT, endovascular treatment; NIHSS, National Institutes of Health Stroke Scale; eTICI, expanded thrombolysis in cerebral infarction; ASPECTS, Alberta Stroke Program Early Computed Tomography Score; CT, computed tomography; MT, mechanical thrombectomy; MRI, magnetic resonance imaging; NCCT, noncontrast computed tomography; CTA, computed tomography angiographt; GA, general anesthesia; DTR, doorto-angiographic reperfusion; sICH; symptomatic intracranial hemorrhage; PTV, peak time of venous outflow; NW, net water uptake; NLR neutrophil to lymphocyte ratio; CysC, cystatin C; MMP-9, matrix metalloproteinase-9; ANC, absolute neutrophil count; AMC, absolute monocyte count; ALC, absolute lymphocyte count; LXA4, lipoxin A4; LTB4, leukotriene B4. DOI: 10.1159/000528922 real world is particularly subjected to paucity.…”