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. 2020 May;22(2):225-233.
doi: 10.5853/jos.2019.02908. Epub 2020 May 31.

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

Basile Kerleroux  1 , Kevin Janot  1 , Cyril Dargazanli  2 , Dimitri Daly-Eraya  2 , Wagih Ben-Hassen  3 , François Zhu  4 , Benjamin Gory  4 , Jean François Hak  5 , Charline Perot  6 , Lili Detraz  7 , Romain Bourcier  7 , Aymeric Rouchaud  8 , Géraud Forestier  8 , Joseph Benzakoun  3 , Gaultier Marnat  9 , Florent Gariel  9 , Pasquale Mordasini  10 , Johannes Kaesmacher  10 , Grégoire Boulouis  3 ; JENI Research Collaborative  1
Affiliations

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

Basile Kerleroux et al. J Stroke. 2020 May.

Abstract

Background and purpose: Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.

Methods: This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0-3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).

Results: A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.

Conclusion: s In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.

Keywords: Acute stroke; Endovascular treatment; Ischemic stroke; Perfusion imaging; Thrombectomy.

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Figures

Figure 1.
Figure 1.
Flow chart. DWI, diffusion weighted imaging; ASPECTS, Alberta Stroke Program Early Computed Tomography Score; PWI, perfusion weighted imaging; MT, mechanical thrombectomy.
Figure 2.
Figure 2.
Modified Rankin Scale at 3 months and initial diffusion weighted imaging (DWI) core volume and mismatch ratio per group.
Figure 3.
Figure 3.
Probability of favourable functional outcome (A) or functional independence (B) by mismatch ratio, in patient receiving mechanical thrombectomy (yellow), and in the control group (blue).
Figure 4.
Figure 4.
Modified Rankin Scale (mRS) distribution in patients receiving mechanical thrombectomy (MT) and those not receiving MT, stratified by core perfusion mismatch ratio (CPMR). IV, intravenous.
See this image and copyright information in PMC

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