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Multicenter Study
. 2022 Jan 1;79(1):22-31.
doi: 10.1001/jamaneurol.2021.4082.

Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion

Thanh N Nguyen  1   2 , Mohamad Abdalkader  2 , Simon Nagel  3 , Muhammad M Qureshi  2   4 , Marc Ribo  5 , Francois Caparros  6 , Diogo C Haussen  7 , Mahmoud H Mohammaden  7 , Sunil A Sheth  8 , Santiago Ortega-Gutierrez  9 , James E Siegler  10 , Syed Zaidi  11 , Marta Olive-Gadea  5 , Hilde Henon  6 , Markus A Möhlenbruch  12 , Alicia C Castonguay  11 , Stefania Nannoni  13 , Johannes Kaesmacher  14   15 , Ajit S Puri  16 , Fatih Seker  12 , Mudassir Farooqui  9 , Sergio Salazar-Marioni  8 , Anna L Kuhn  16 , Artem Kaliaev  2 , Behzad Farzin  17 , William Boisseau  17 , Hesham E Masoud  18 , Carlos Ynigo Lopez  18 , Ameena Rana  10 , Samer Abdul Kareem  19 , Anvitha Sathya  1 , Piers Klein  2 , Mohammad W Kassem  19 , Peter A Ringleb  3 , Charlotte Cordonnier  6 , Jan Gralla  14 , Urs Fischer  20   21 , Patrik Michel  13 , Tudor G Jovin  10 , Jean Raymond  17 , Osama O Zaidat  19 , Raul G Nogueira  7
Affiliations
Multicenter Study

Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion

Thanh N Nguyen et al. JAMA Neurol. .

Erratum in

  • Error in Author Name.
    [No authors listed] [No authors listed] JAMA Neurol. 2022 Jan 1;79(1):93. doi: 10.1001/jamaneurol.2021.4854. JAMA Neurol. 2022. PMID: 35006268 Free PMC article. No abstract available.

Abstract

Importance: Advanced imaging for patient selection in mechanical thrombectomy is not widely available.

Objective: To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window.

Design, setting, and participants: This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset.

Exposures: Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI.

Main outcomes and measures: The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality.

Results: Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio [aOR], 0.95 [95% CI, 0.77-1.17]; P = .64) or CT vs MRI (aOR, 0.95 [95% CI, 0.8-1.13]; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 [95% CI, 0.7-1.16]; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 [95% CI, 0.64-0.98]; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 [88.9%] and 670 [89.5%] vs 250 [78.9%]; P < .001). No significant differences in symptomatic intracranial hemorrhage (CT, 42 [8.1%]; CTP, 43 [5.8%]; MRI, 15 [4.7%]; P = .11) or 90-day mortality (CT, 125 [23.4%]; CTP, 159 [21.1%]; MRI, 62 [19.5%]; P = .38) were observed.

Conclusions and relevance: In patients undergoing proximal anterior circulation mechanical thrombectomy in the extended time window, there were no significant differences in the clinical outcomes of patients selected with noncontrast CT compared with those selected with CTP or MRI. These findings have the potential to widen the indication for treating patients in the extended window using a simpler and more widespread noncontrast CT-only paradigm.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Nguyen reported research support from Medtronic and the Society of Vascular and Interventional Neurology with data safety monitoring board involvement for Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA), Endovascular Therapy for Low NIHSS Ischemic Strokes (ENDOLOW), a Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT 2), pRESET for Occlusive Stroke Treatment (PROST), Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), and Workflow Optimization to Reduce Time to Endovascular Reperfusion in Stroke Treatment (WE-TRUST) trials. Dr Nagel reported personal fees for consultancy for Brainomix and payment for lectures including speaker bureaus with Boehringer Ingelheim and Pfizer outside the submitted work. Dr Ribo reported being a cofounder of Anaconda Biomed; a consultant with Methinks, Medtronic, Cerenovus, Apta Targets, Anaconda Biomed, and Philips; and grants from CVAid, outside the submitted work. Dr Haussen reported being a consultant for Stryker, Vesalio, Cerenovus, and Jacobs Institute and holding stock options with VizAi during the conduct of the study. Dr Siegler reported consulting fees from Ceribell and speakers’ bureau involvement with AstraZeneca outside the submitted work. Dr Ortega-Gutierrez reports being a consultant for Medtronic and Stryker Neurovascular and receiving grants from Stryker, IschemiaView, Viz.ai, and Siemens. Dr Möhlenbruch reports consultancy at Medtronic, MicroVention, and Stryker; grants or grants pending from Medtronic, Stryker, Balt, and MicroVention (money paid to his institution); and payment for lectures including service on speakers’ bureaus from Medtronic, MicroVention, and Stryker, outside the submitted work. Dr Zaidat reported consulting fees for Stryker, Medtronic, Cerenovus, and Penumbra; research grants from Stryker, Medtronic, Cerenovus, Penumbra, and Genentech; in addition, Dr Zaidat had a patent for Ischemic Stroke issued. Dr Sheth reported research grants from the National Institutes of Health (grants U18EB029353 and R01NS121154) and American Academy of Neurology/the Society of Vascular and Interventional Neurology and consultancy fees from Penumbra and Cerenovus. Dr Fischer reported research grants from Medtronic (BEYOND SWIFT and SWIFT DIRECT); serving as consultant for Medtronic, Stryker, CSL Behring; and participating in an advisory board for Alexion/Portola outside the submitted work. Dr Jovin reported being an investigator with Stryker (DAWN and AURORA trials); an advisor or investor for Anaconda, Route92, VizAi, FreeOx, Methinks, and Blockade Medical; a recipient of personal fees, data safety monitoring board, and steering committee fees from Cerenovus and grants from Medtronic; an advisor and stockholder for Corindus; and a member of a medical committee for Contego outside the submitted work. Dr Nogueira reported involvement with Stryker as part of the DAWN trial; the Trevo-2 trial and Trevo registry steering committee; Medtronic as part of the SWIFT/SWIFT-PRIME steering committee and STAR trial core laboratory; Penumbra as part of the 3D Trial executive committee; Cerenovus/Neuravi as part of the ENDOLOW Trial, EXCELLENT Registry, and ARISE-2 trial steering committee; Phenox as part of the PROST Trial; Imperative Care as part of the Imperative Trial; and Philips as part of the WE-TRUST trial. Dr Nogueira also reported consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, and Perfuze; and investments in Viz-AI, Perfuze, Cerebrotech, Reist/Q'Apel Medical, Truvic, and Viseon. Dr Kaesmacher reported grants from SAMW/Bangerter Foundation, Swiss Stroke Society, and CTU Bern outside the submitted work. Dr Puri reported personal fees from Stryker Neurovascular, Cerenovus, Medtronic, Merit, CereVasc, Microvention, and Arsenal Medical; stocks with InNeuroCo, Galaxy, NTI, Agile, and Perfuze; and grants from the National Institutes of Health outside the submitted work. Dr Kaliaev reported grants from Medtronic and SVIN during the conduct of the study. Dr Ringleb reported personal fees from Boehringer Ingelheim, Bayer, Bristol Myers Squibb, and Pfizer outside the submitted work. Dr Cordonnier reported personal fees from Boehringer Ingelheim and advisory board participation from Bristol Myers Squibb, AstraZeneca, and Biogen outside the submitted work. Dr Gralla reported grants from Medtronic (SWIFT DIRECT trial) and SNF outside the submitted work. Dr Michel reported grants from Swiss National Science Foundation and Swiss Heart Foundation outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flow Diagram
ASPECTS indicates Alberta Stroke Program Early Computed Tomography Score; ICA, internal carotid artery; MCA, middle cerebral artery; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; TLSW, time last seen well; TPA, tissue plasminogen activator.
Figure 2.
Figure 2.. Distribution of 90-Day Modified Rankin Scale Score (mRS) in Patients Presenting in the Window 6 to 24 Hours After Time Last Seen Well With Internal Carotid Artery and Middle Cerebral Artery M1/M2 Occlusions, by Imaging Modality
Scores range from 0 to 6, with 0 indicating no symptoms; 1, no clinically significant disability; 2, slight disability (the patient is able to look after their own affairs without assistance but unable to carry out all previous activities); 3, moderate disability (patient requires some help but is able to walk unassisted); 4, moderately severe disability (patient is unable to attend to bodily needs without assistance and unable to walk unassisted); 5, severe disability (patient requires constant nursing care and attention); and 6, death. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by computed tomography (CT) vs CT perfusion (CTP) (adjusted odds ratio, 0.95 [95% CI, 0.77-1.17]; P = .64) or CT vs magnetic resonance imaging (adjusted odds ratio, 0.95 [95% CI, 0.8-1.13]; P = .55).
See this image and copyright information in PMC

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References

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