Predictors of reperfusion in patients with acute ischemic stroke

Abstract

Background and purpose: Ischemic stroke studies emphasize a difference between reperfusion and recanalization, but predictors of reperfusion have not been elucidated. The aim of this study was to evaluate the relationship between reperfusion and recanalization and identify predictors of reperfusion.

Materials and methods: From the Dutch Acute Stroke Study, 178 patients were selected with an MCA territory deficit on admission CTP and day 3 follow-up CTP and CTA. Reperfusion was evaluated on CTP, and recanalization on CTA, follow-up imaging. Reperfusion percentages were calculated in patients with and without recanalization. Patient admission and treatment characteristics and admission CT imaging parameters were collected. Their association with complete reperfusion was analyzed by using univariate and multivariate logistic regression.

Results: Sixty percent of patients with complete recanalization showed complete reperfusion (relative risk, 2.60; 95% CI, 1.63-4.13). Approximately one-third of patients showed some discrepancy between recanalization and reperfusion status. Lower NIHSS score (OR, 1.06; 95% CI, 1.01-1.11), smaller infarct core size (OR, 3.11; 95% CI, 1.46-6.66; and OR, 2.40; 95% CI, 1.14-5.02), smaller total ischemic area (OR, 4.20; 95% CI, 1.91-9.22; and OR, 2.35; 95% CI, 1.12-4.91), lower clot burden (OR, 1.35; 95% CI, 1.14-1.58), distal thrombus location (OR, 3.02; 95% CI, 1.76-5.20), and good collateral score (OR, 2.84; 95% CI, 1.34-6.02) significantly increased the odds of complete reperfusion. In multivariate analysis, only total ischemic area (OR, 6.12; 95% CI, 2.69-13.93; and OR, 1.91; 95% CI, 0.91-4.02) was an independent predictor of complete reperfusion.

Conclusions: Recanalization and reperfusion are strongly associated but not always equivalent in ischemic stroke. A smaller total ischemic area is the only independent predictor of complete reperfusion.

Fig 1.

Inclusion flow chart.

Fig 2.

Relation between recanalization and reperfusion. A, A patient with complete recanalization without complete reperfusion. Admission NCCT shows no early CT signs. Follow-up NCCT shows infarction of the basal ganglia. Admission CTA shows occlusion of the M1 segment (arrow). Follow-up CTA shows complete recanalization; no distal M3 occlusion could be found. Admission CTP shows a large area of decreased MTT and CBV in ASPECTS M5 and M6. Follow-up CTP shows a residual perfusion deficit ASPECTS M6 on the MTT and CBV maps (arrow). B, A patient with incomplete recanalization but complete reperfusion. Admission NCCT shows some early CT signs in the MCA territory. Follow-up NCCT shows areas of infarction in a large part of the MCA territory. Admission CTA shows an occlusion in the M1 and M2 segments of the MCA. Follow-up CTA shows a short residual occlusion in an M2 segment (arrows). Admission CTP shows a large area of decreased MTT and CBV in ASPECTS M1–M3, which has completely resolved on follow-up.