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. 2012 Feb;33(2):336-42.
doi: 10.3174/ajnr.A2746. Epub 2011 Nov 17.

Reperfusion by combined thrombolysis and mechanical thrombectomy in acute stroke: effect of collateralization, mismatch, and time to and grade of recanalization on clinical and tissue outcome

Affiliations

Reperfusion by combined thrombolysis and mechanical thrombectomy in acute stroke: effect of collateralization, mismatch, and time to and grade of recanalization on clinical and tissue outcome

V Hesselmann et al. AJNR Am J Neuroradiol. 2012 Feb.

Abstract

Background and purpose: Our research focuses on interventional neuroradiology (stroke treatment including imaging methods) and general neuroimaging with an emphasis on functional MR imaging. Our aim was to determine the efficacy of revascularization (TIMI) of middle cerebral and/or carotid artery occlusion by means of mechanical recanalization techniques and to evaluate the impact of collateralization, mismatch in perfusion CT, time to revascularization, grade of revascularization on tissue, and clinical outcome in patients with acute ischemic stroke.

Materials and methods: Thirty-one patients with MCA and/or ICA occlusion were included. Ischemic stroke was diagnosed by NECT, CTA, and volume PCT for grading collateralization and mismatch. Time to recanalization was measured from the onset of stroke to the time point of DSA-proved mechanical recanalization. Tissue outcome was calculated by segmentation of infarct size between pre- and postinterventional CT and percentage mismatch lost. Clinical outcome was determined by the mRS.

Results: Twenty-one of 31 patients (61.8%) presented with MCA and 10/31 patients (38.2%), with distal ICA occlusions. Sufficient recanalization (TIMI 2 and 3) was achieved in 23/31 (75%). Clinical evaluation revealed an mRS score of ≤2 in 25.5%. Age (r = 0.439, P = .038) and TIMI (r = 0.544, P = .002) showed the strongest correlation with clinical outcome. Time to recanalization, TIMI score, and mismatch were associated with a good tissue outcome in ANOVA.

Conclusions: Favorable outcome after mechanical recanalization of acute MCA and ICA occlusion depends on time to and grade of recanalization, mismatch, and collateralization. These results indicate that multimodal stroke imaging is helpful to guide therapy decisions and to indicate patients amenable for mechanical recanalization.

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Figures

Fig 1.
Fig 1.
A and B, MTT and rCBV maps for estimating the extent of penumbra and the infarct core. C, The difference in size of the infarct core and penumbra. D, The final infarct as shown with NECT and the mismatch lost in percentages are calculated by Analyze software.
Fig 2.
Fig 2.
Work-up of patients with acute ischemic stroke. The flow chart of the work-up procedures was determined in cooperation with the Departments of Neurology and Anesthesiology.
Fig 3.
Fig 3.
Boxplot analyses of the predictive factors for infarct growth. A, Boxplot analysis for the factor “mismatch” for the whole group (1, mismatch; 2, no mismatch) demonstrates a higher percentage mismatch lost (permisloss) for patients without mismatch (2) in preinterventional stroke CT. B, Boxplot analysis for mismatch for the Penumbra subgroup (1, mismatch; 2, no mismatch) shows a greater difference of permisloss between patients with mismatch (1) in comparison with patients without mismatch (2) in preinterventional stroke CT. C, Boxplot analysis for the factor “collateralization” shows a higher permisloss for poor collateralization (3) with the most pronounced difference between good (1) and moderate (2) collateralization in preinterventional CT. Zero indicates missing values (n = 3). D, Boxplot analysis for the factor collateralization for the Penumbra subgroup shows a comparable relation (as in C) between an increasing percentage mismatch lost and a decreasing extent of collaterals (1, good collaterals; 2, moderate collaterals; 3, no collaterals; 0, missing values). E, Boxplot analysis for the factor TIMI for the whole group (TIMI 0, poor; 1, moderate; 2, good; 3, complete) shows a reduction of percentage mismatch lost with increasing recanalization grades. F, Boxplot analysis for the factor “TIMI” for the Penumbra subgroup (TIMI 1, poor; 2, moderate; 3, good; 4, complete) shows a reduction of percentage mismatch lost with higher recanalization grades.

References

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