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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Relative Influence of Capillary Index Score, Revascularization, and Time on Stroke Outcomes From the Interventional
Firas Al-Ali1, John J Elias2, Thomas A Tomsick2
1From the Departments of Neuro-Interventional Surgery (F.A.-A.) and Research (J.J.E.), Akron General Medical Center, OH; Department of Radiology, University of Cincinnati Academic Health Center, OH (T.A.T.); Neurovascular Imaging Research Core & UCLA Department of Neurology, Los Angeles, CA (D.S.L.); and Department of Neurology, University of Cincinnati Academic Health Center, OH (J.P.B.). falali@snsphysicians.com.
Insights
Improving patient selection with the capillary index score (CIS) may enhance outcomes for acute ischemic stroke (AIS) patients undergoing endovascular therapy. This score, alongside reperfusion success, predicts good recovery after stroke treatment.
Area of Science:
- Neurology
- Interventional Radiology
- Stroke Medicine
Background:
- Acute ischemic stroke (AIS) treatment outcomes have historically been poor with endovascular therapy.
- Previous trials have not consistently demonstrated endovascular therapy's benefit over standard care.
- Optimizing patient selection is crucial for improving reperfusion success.
Purpose of the Study:
- To investigate the utility of the capillary index score (CIS) for patient selection in AIS.
- To determine if CIS can predict outcomes following endovascular therapy.
- To evaluate the correlation between CIS, reperfusion, and functional outcomes.
Main Methods:
- Calculated CIS from pretreatment angiograms in 78 AIS patients from the Interventional Management of Stroke III database.
- Dichotomized CIS into favorable (fCIS) and poor (pCIS) groups.
- Used logistic regression to analyze the relationship between CIS, time to revascularization, reperfusion (modified thrombolysis in cerebral infarction score), and 90-day functional outcome (modified Rankin Scale).
Main Results:
- Capillary index score (CIS) and reperfusion success (modified thrombolysis in cerebral infarction score) were significant predictors of good outcomes (P<0.01).
- Patients with a favorable CIS and successful reperfusion achieved good outcomes (modified Rankin Scale ≤2) in 71% of cases.
- Conversely, patients with a poor CIS and successful reperfusion had good outcomes in only 13% of cases.
Conclusions:
- CIS is a strong predictor of outcomes in patients undergoing endovascular reperfusion for AIS.
- Utilizing CIS for patient selection can potentially improve the success rates of endovascular therapy.
- Further validation through a randomized controlled trial is warranted to confirm these findings.
Background And Purpose:
Until recently, acute ischemic stroke (AIS) trials have failed to show a benefit of endovascular therapy compared with standard therapy, leading some authors to recommend decreasing the time from ictus to revascularization to improve outcomes. We hypothesize that improving patient selection using the capillary index score (CIS) may also be a useful strategy.
Methods:
CIS was calculated, blinded to outcome, from pretreatment diagnostic cerebral angiograms for 78 subjects in the Interventional Management of Stroke III database with internal carotid artery and middle cerebral artery trunk occlusion. The CIS was dichotomized into favorable (fCIS=2 or 3) and poor (pCIS=0 or 1). Outcomes were categorized based on the modified Rankin Scale score at 90 days (0-2 considered a good outcome). Modified thrombolysis in cerebral infarction score 2b or 3 was considered good revascularization. Multivariable logistic regression was performed to relate CIS, time from ictus to revascularization, modified thrombolysis in cerebral infarction score, and National Institue of Health Stroke Scale score to good outcomes.
Results:
Only CIS and modified thrombolysis in cerebral infarction scores were correlated with good outcomes (P<0.01). Patients with fCIS and good revascularization achieved 71% modified Rankin Scale≤2, compared with 13% for patients with pCIS and good revascularization.
Conclusions:
In this subset of patients from the Interventional Management of Stroke III Trial, CIS and modified thrombolysis in cerebral infarction were strong predictors of outcome after endovascular reperfusion. Using the CIS to improve patient selection could be a powerful strategy to improve rate of good outcomes in endovascular therapy. A randomized trial is needed.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424.
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