Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

Albers, Gregory W.; Marks, Michael P.; Kemp, Stephanie; Christensen, Søren; Tsai, Jenny P; Ortega‐Gutiérrez, Santiago; McTaggart, Ryan; Torbey, Michel T.; Kim-Tenser, May; Leslie‐Mazwi, Thabele M; Sarraj, Amrou; Kasner, Scott E.; Ansari, Sameer A.; Yeatts, Sharon D.; Hamilton, Scott; Mlynash, Michael; Heit, Jeremy J; Zaharchuk, Greg; Kim, Sun; Carrozzella, Janice; Palesch, Yuko Y.; Demchuk, Andrew M.; Bammer, Roland; Lavori, Philip W.; Broderick, Joseph P.; Lansberg, Maarten G.

doi:10.1056/nejmoa1713973

Cited by 3,544 publications

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“…Several trials used perfusion imaging as an imaging inclusion criterion [4, 20, 24]. Two studies included patients for EVT randomization if the mismatch ratio between critical hypoperfusion and the infarct core was more than 1.2 [4, 20] and another with a mismatch of more than 1.8 [3]. Of the > 6 h WUS patients with a proximal occlusion in our study, 61 and 44% fulfilled these criteria, and therefore would be eligible for EVT.…”

Section: Discussionmentioning

confidence: 99%

“…For all WUS patients and patients with a proximal occlusion of the anterior circulation eligible for EVT, it was additionally determined whether the mismatch between the total ischemic area and the infarct core was more than 1.2 [20] or more than 1.8 [3], and whether the infarct core volume was ≤50 mL [4]. Patients with no perfusion deficit were grouped in the favorable mismatch groups.…”

Section: Methodsmentioning

confidence: 99%

“…If there is moderate to good collateral filling and a favorable Alberta Stroke Program Early CT Score (ASPECTS), with a lower limit ranging from 5 to 7, EVT can be considered up to 12 h after symptom onset [2]. A recent trial has even shown that patients can be selected for EVT up to 24 h when using MR DWI or CT-perfusion (CTP) [3, 4]. …”

Section: Introductionmentioning

confidence: 99%

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Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

et al. 2018

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Background: Current guidelines for the treatment of acute ischemic stroke are mainly based on the time between symptom onset and initiation of treatment. This time is unknown in patients with wake-up stroke (WUS). We investigated clinical and multimodality CT imaging characteristics on admission in patients with WUS and in patients with a stroke with a known onset time. Methods: All patients were selected from a large prospective cohort study (Dutch acute stroke study). WUS patients last seen well > 4.5 and ≤4.5 h were separately compared to patients with a known onset time ≤4.5 h. In addition, WUS patients with a proximal occlusion of the anterior circulation last seen well > 6 and ≤6 h were separately compared to patients with a known onset time ≤6 h and a proximal occlusion. National Institute of Health Stroke Score, age, gender, history of atrial fibrillation, non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS), CT-perfusion abnormalities, proximal occlusions, and collateral filling on CT angiography were compared between groups using the Mann-Whitney U test and Fisher’s exact test. Results: WUS occurred in 149/1,393 (10.7%) patients. Admission clinical and imaging characteristics of WUS patients last seen well > 4.5 h (n = 81) were not different from WUS patients last seen well ≤4.5 h (n = 68). Although WUS patients last seen well > 4.5 h had a significantly lower NCCT ASPECTS than patients with a known time of stroke symptom onset of ≤4.5 h (n = 1,026), 85.2% had an NCCT ASPECTS > 7 and 75% had a combination of favorable ASPECTS > 7 and good collateral filling. There were no statistically significant differences between the admission clinical and imaging characteristics of WUS patients with proximal occlusions last seen well > 6 h (n = 23), last seen well ≤6 h (n = 40), and patients with a known time to stroke symptom onset ≤6 h (n = 399). Of all WUS patients with proximal occlusions last seen well > 6 h, only 4.3% had severe ischemia (ASPECTS < 5), 13 (56.5%) had ASPECTS > 7 and good collateral filling. Conclusions: There are only minor differences between clinical and imaging characteristics of WUS patients and patients who arrive in the hospital within the time criteria for intravenous or endovascular treatment. Therefore, CT imaging may help to identify WUS patients who would benefit from treatment and rule out those patients with severe ischemia and poor collaterals.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

et al. 2018

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“…The rheological and pathophysiological changes are visualized through collateral or perfusion imaging, by which decision-making for recanalization treatment was usually made. The proportion of trial eligibility was 52% in this cohort [2, 3]. …”

Section: Discussionmentioning

confidence: 99%

“…Ischemic penumbra maintained by collateral circulation mitigates acute hypoperfusion and cerebral ischemic injuries, thus being a key target of acute revascularization treatment [2, 3]. Recently published 2 randomized clinical trials demonstrated the efficacy of endovascular recanalization (EVT) treatment for acute ischemic stroke patients that arrived later than the conventional time window of 6 h [2, 3]. Individual property of collateral circulation was indicated to explain trials’ results that tenacious collateral may protect ischemic tissues at risk for an extended period of time [4].…”

Section: Introductionmentioning

confidence: 99%

Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6–12 h after Onset

Kim

Jeong

et al. 2018

Cerebrovasc Dis

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Background: Clinical trials have shown that benefits of endovascular recanalization (EVT) for acute ischemic stroke patients with sizable penumbral tissues seems plausible even beyond 6 h after their last seen normal (LSN). Persistency of ischemic penumbra remains unclear in delayed periods. Methods: From a prospective stroke registry database, we identified 111 acute ischemic stroke patients who had internal carotid artery or middle cerebral artery occlusion with baseline National Institutes of Health Stroke Scale scores ≥6 points and arrived 6–12 h after LSN. Baseline information and functional outcomes were prospectively collected as a clinical registry. Attending physicians made treatment decisions for EVT based on the current guidelines and institutional protocols. MR image parameters, including the volume of diffusion-restricted lesions and mapping of the hypoperfused area, were quantified using automated commercial software. Binary logistic regression analysis models, with modified Rankin Scale (mRS) scores of 0–1 at 3 months after stroke included as a dependent variable, were constructed. Results: Between 6 and 12 h after onset, 58% had a mismatch ratio of ≥1.8 at baseline and 42% had favorable imaging profiles as determined by DEFUSE 2 study. After 9 h, there was a mismatch ratio of ≥1.8 in 47 and 38% favorable profiles. EVT was performed in 54% of cases. A 3-month mRS score of 0–1 was found in 19% (25% in EVT and 12% in medical treatment groups) of cases. EVT was associated with an increased OR of having a mRS score of 0–1 at 3 months after stroke (adjusted OR 7.59 [95% CI 1.28–61.60]). Conclusions: Penumbral tissues were persistent in a substantial proportion of anterior circulation occlusion cases 6–12 h after LSN. EVT at 6–12 h in a predominantly Asian cohort resulted in better outcomes.

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The Acute Stroke Care Revolution

Josephson

Kamel

2018

JAMA

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Stroke is an important public health issue, affecting 800 000 individuals in the United States yearly and leading to 140 000 deaths. 1 The morbidity of stroke is substantial and contributes to serious neurologic disability and reduced quality of life in the majority of those affected. 1 Patients with acute ischemic stroke, which accounts for approximately 85% of individuals with stroke in the United States, present to emergency departments hoping for interventions that will quickly reverse neurologic deficits and restore function. It is clear that speed matters ("time is brain") because every additional minute of ischemia is estimated to lead to the death of perhaps 2 million neurons. 2 Prior to 2015, acute treatment options with a good evidence base were limited to intravenous tissue plasminogen activator (IV t-PA, alteplase), which generally can be given within, at most, 4.5 hours from the last time the patient was seen well without signs and symptoms of stroke. This narrow time window precluded many patients from receiving any acute therapy for stroke because they were deemed not eligible for tissue plasminogen activator treatment, often related to delayed presentations outside of this time window. 3 Startinginlate2014,aseriesofrandomizedtrialsdemonstrated the efficacy of clot extraction (thrombectomy) for the approximately one-third of patients with ischemic stroke with large-vessel occlusions (LVOs) in the anterior circulation. These trials included patients who presented VIEWPOINT

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Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

Cited by 3,544 publications

References 22 publications

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6–12 h after Onset

The Acute Stroke Care Revolution

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