Reperfusion Without Functional Independence in Late Presentation of Stroke With Large Vessel Occlusion

Abstract

Background: Reperfusion without functional independence (RFI) is an undesired outcome following thrombectomy in acute ischemic stroke. The primary objective was to evaluate, in patients presenting with proximal anterior circulation occlusion stroke in the extended time window, whether selection with computed tomography (CT) perfusion or magnetic resonance imaging is associated with RFI, mortality, or symptomatic intracranial hemorrhage (sICH) compared with noncontrast CT selected patients. Methods: The CLEAR study (CT for Late Endovascular Reperfusion) was a multicenter, retrospective cohort study of stroke patients undergoing thrombectomy in the extended time window. Inclusion criteria for this analysis were baseline National Institutes of Health Stroke Scale score ≥6, internal carotid artery, M1 or M2 segment occlusion, prestroke modified Rankin Scale score of 0 to 2, time-last-seen-well to treatment 6 to 24 hours, and successful reperfusion (modified Thrombolysis in Cerebral Infarction 2c–3). Results: Of 2304 patients in the CLEAR study, 715 patients met inclusion criteria. Of these, 364 patients (50.9%) showed RFI (ie, mRS score of 3–6 at 90 days despite successful reperfusion), 37 patients (5.2%) suffered sICH, and 127 patients (17.8%) died within 90 days. Neither imaging selection modality for thrombectomy candidacy (noncontrast CT versus CT perfusion versus magnetic resonance imaging) was associated with RFI, sICH, or mortality. Older age, higher baseline National Institutes of Health Stroke Scale, higher prestroke disability, transfer to a comprehensive stroke center, and a longer interval to puncture were associated with RFI. The presence of M2 occlusion and higher baseline Alberta Stroke Program Early CT Score were inversely associated with RFI. Hypertension was associated with sICH. Conclusions: RFI is a frequent phenomenon in the extended time window. Neither magnetic resonance imaging nor CT perfusion selection for mechanical thrombectomy was associated with RFI, sICH, and mortality compared to noncontrast CT selection alone. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04096248.

Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy

“…Many studies have shown that patient selection using ASPECTS on NCCT scan and/or the collateral circulation on multi-phase CTA can be a reasonable alternative to advanced imaging to select patients for EVT in the late window. 4,13,69,109,117,118 In a multinational cohort of 1,604 patients presenting with LVO in the extended window, patients selected by NCCT had comparable clinical and safety outcomes with patients selected by CTP or MRI. 13 A real-world observational study found that EVT may be safe and effective in patients with wake-up stroke and late-presenting stroke selected using clinical-core mismatch (high NIHSS/high ASPECTS in NCCT).…”

“…15,95,96,99,102,103,107 Recent guidelines have not been as restrictive in the imaging selection paradigms for late window presenting patients. 4,7,8,11,108,109 Both the DEFUSE-3 and DAWN trials used CTP over MRI perfusion due to its wider availability, faster acquisition, fewer contraindications, and decreased cost of CT-based images. 5,107,110 Both trials also used an automated program (RAPID, iSchemaView, Menlo Park, CA, USA) to estimate volumes of ischemic core (rCBF <30%) and critical hypoperfusion (using Tmax >6 s).…”

“…114 Other observational cohort studies have since corroborated the positive outcomes following EVT in extended window trial-ineligible patients. 4,109,112,115,116 Given the limitations of advanced imaging, more simplified imaging protocols could potentially result in the treatment of a larger proportion of stroke patients presenting in the late window while still maintaining the benefit of EVT. Many studies have shown that patient selection using ASPECTS on NCCT scan and/or the collateral circulation on multi-phase CTA can be a reasonable alternative to advanced imaging to select patients for EVT in the late window.…”

“…1 Recent advances in neuroimaging modalities have helped identify patients who may or may not benefit from endovascular treatment (EVT). [2][3][4] Imaging played a critical role in the selection of patients into acute ischemic stroke (AIS) randomized controlled trials (RCTs), both in the early and late windows of patient presentation. 5 After their publication, the 2019 American Heart Association/American Stroke Association (AHA/ASA), the European Stroke Organization, Korean Stroke Guidelines, Chinese Stroke Association, and Canadian Stroke Guidelines were updated to recommend obtaining advanced or multimodal imaging for EVT patient triage and selection especially for late window treatment.…”

“…It can be used to confirm the diagnosis and to guide acute treatment options by excluding acute hemorrhage, confirming vessel occlusion or stenosis, assessing tissue viability with perfusion estimates, and evaluating collateral circulation [ 1 ]. Recent advances in neuroimaging modalities have helped identify patients who may or may not benefit from endovascular treatment (EVT) [ 2 - 4 ].…”