Younger Stroke Patients With Large Pretreatment Diffusion-Weighted Imaging Lesions May Benefit From Endovascular Treatment

Abstract

Background and Purpose— Lesion volume on diffusion-weighted magnetic resonance imaging (DWI) before acute stroke therapy is a predictor of outcome. Therefore, patients with large volumes are often excluded from therapy. The aim of this study was to analyze the impact of endovascular treatment in patients with large DWI lesion volumes (>70 mL). Methods— Three hundred seventy-two patients with middle cerebral or internal carotid artery occlusions examined with magnetic resonance imaging before treatment since 2004 were included. Baseline data and 3 months outcome were recorded prospectively. DWI lesion volumes were measured semiautomatically. Results— One hundred five patients had lesions >70 mL. Overall, the volume of DWI lesions was an independent predictor of unfavorable outcome, survival, and symptomatic intracerebral hemorrhage ( P <0.001 each). In patients with DWI lesions >70 mL, 11 of 31 (35.5%) reached favorable outcome (modified Rankin scale score, 0–2) after thrombolysis in cerebral infarction 2b-3 reperfusion in contrast to 3 of 35 (8.6%) after thrombolysis in cerebral infarction 0-2a reperfusion ( P =0.014). Reperfusion success, patient age, and DWI lesion volume were independent predictors of outcome in patients with DWI lesions >70 mL. Thirteen of 66 (19.7%) patients with lesions >70 mL had symptomatic intracerebral hemorrhage with a trend for reduced risk with avoidance of thrombolytic agents. Conclusions— There was a growing risk for poor outcome and symptomatic intracerebral hemorrhage with increasing pretreatment DWI lesion volumes. Nevertheless, favorable outcome was achieved in every third patient with DWI lesions >70 mL after successful endovascular reperfusion, whereas after poor or failed reperfusion, outcome was favorable in only every 12th patient. Therefore, endovascular treatment might be considered in patients with large DWI lesions, especially in younger patients.

Does Diffusion Lesion Volume Above 70 mL Preclude Favorable Outcome Despite Post-Thrombolysis Recanalization?

“…This is consistent with the few studies that reported on the outcome of patients treated despite large initial DWI lesions. Thus, Gilgen et al 17 reported that 21% of 66 such patients had favorable outcome, in accordance with the one in 6 with favorable outcome in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) study. 8 A second and even more important finding from our study is that recanalization was associated with favorable outcome in patients with DWI≥70 mL.…”

“…Two hundred and six were excluded because of bridging therapy (n=32), inclusion in a neuroprotection study (n=4), non-middle cerebral artery stroke (n=53), baseline evaluation with CT only (n=36), initial MRI not available in Digital and Communications in Medicine (DICOM) format (n=16), no visible initial occlusion (n=42), no data on recanalization (n=9), or 90-day modified Rankin scale score not available (n=14). Of note, the latter 14 patients had similar NIHSS at 24 hours than the included patients (median 9 [interquartile range 6-14] versus 11 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]; P=0.72). Excluded patients did not differ from the included patients for age or onset-to-MRI time, but had lower baseline NIHSS (median 10 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] versus 15 [9][10][11][12][13][14][15][16][17][18][19][20]; P<0.0001).…”

“…[16][17][18][19] In a recently reported large series of patients treated with EVT, favorable outcome was achieved after reperfusion in every third patient with DWI lesions >70 mL, whereas after poor or failed reperfusion, outcome was favorable in only every 12th patient. 17 Another point to consider is that DWI lesion cut points above which recanalization may be futile have to date been derived from studies where patients were treated in a late time window, [8][9][10] and so may not apply to patients treated earlier. For instance, 2 EVT studies have been discrepant; as in one, the treatment was futile for DWI lesions >70 mL when recanalization occurred at a mean (±SD) 7.4±3.1 hours, 10 whereas in the other, some patients with large DWI lesions benefited from earlier-initiated endovascular recanalization.…”

Impact of Initial Diffusion-Weighted Imaging Lesion Growth Rate on the Success of Endovascular Reperfusion Therapy

“…However, we did demonstrate with others that some patients with large infarction defining a malignant profile with a DWI lesion volume of >70 mL may still benefit from an emergent revascularization within 6 hours. [8][9][10] With this as a background, we aim to investigate first the characteristics of IGR in a cohort of consecutive patients experiencing an acute BI downstream of a proximal ICA term/M1 occlusion treated by endovascular treatment within 6 hours after onset and imaged by MR-DWI before treatment, and second its impact on the rate of favorable outcome according to the occurrence of a successful recanalization. …”

Segabrottnám við brátt blóðþurrðarslag er mesta framför í læknisfræði í áraraðir

“…Eins og staðan er í dag hefur reynst erfitt að skilgreina hóp sjúklinga sem ekki hefur gagn af segabrottnámi. 44,45 Gera þarf frekari framskyggnar rannsóknir, þar sem flestar rannsóknir útilokuðu sjúklinga með stór óaft-urkraef drep. Íhuga aetti segabrottnám hjá sjúklingum með stórt kjarnadrep og hjá sjúklingum sem koma inn nokkrum klukkustundum frá upphafi einkenna.…”