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Updated: Apr 6, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Response to endovascular reperfusion is not time-dependent in patients with salvageable tissue
Maarten G Lansberg1, Carlo W Cereda2, Michael Mlynash2
1From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland. lansberg@stanford.edu.
Objective:
To evaluate whether time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on MRI.
Methods:
Patients from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) cohort study with a perfusion-diffusion target mismatch were included. Reperfusion was defined as a decrease in the perfusion lesion volume of at least 50% between baseline and early follow-up. Good functional outcome was defined as a modified Rankin Scale score ≤2 at day 90. Lesion growth was defined as the difference between the baseline and the early follow-up diffusion-weighted imaging lesion volumes.
Results:
Among 78 patients with the target mismatch profile (mean age 66 ± 16 years, 54% women), reperfusion was associated with increased odds of good functional outcome (adjusted odds ratio 3.7, 95% confidence interval 1.2-12, p = 0.03) and attenuation of lesion growth (p = 0.02). Time to treatment did not modify these effects (p value for the time × reperfusion interaction is 0.6 for good functional outcome and 0.3 for lesion growth). Similarly, in the subgroup of patients with reperfusion (n = 46), time to treatment was not associated with good functional outcome (p = 0.2).
Conclusion:
The association between endovascular reperfusion and improved functional and radiologic outcomes is not time-dependent in patients with a perfusion-diffusion mismatch. Proof that patients with mismatch benefit from endovascular therapy in the late time window should come from a randomized placebo-controlled trial.
Insights
Endovascular reperfusion improves outcomes for stroke patients with salvageable brain tissue, regardless of treatment time. This finding suggests that treatment timing may not be a critical factor for these patients.
Area of Science:
- Neurology
- Radiology
- Interventional Cardiology
Background:
- Stroke treatment relies on timely reperfusion to salvage brain tissue.
- Perfusion-diffusion mismatch on MRI identifies patients with salvageable tissue.
- The influence of treatment delay on reperfusion effectiveness is debated.
Purpose of the Study:
- To determine if treatment time affects endovascular reperfusion outcomes in stroke patients with salvageable tissue.
- To analyze the relationship between time to treatment and functional/radiologic outcomes.
Main Methods:
- Analysis of the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) cohort.
- Inclusion of patients with perfusion-diffusion mismatch identified by MRI.
- Definition of reperfusion as ≥50% perfusion lesion volume reduction.
- Assessment of good functional outcome (modified Rankin Scale ≤2) at 90 days.
- Quantification of lesion growth on diffusion-weighted imaging.
Main Results:
- Reperfusion was linked to better functional outcomes (aOR 3.7, P=0.03) and reduced lesion growth (P=0.02).
- Time to treatment did not significantly alter the benefits of reperfusion (interaction P > 0.3).
- In reperfused patients, treatment time did not correlate with functional outcome (P=0.2).
Conclusions:
- Endovascular reperfusion benefits are not time-dependent in stroke patients with perfusion-diffusion mismatch.
- Further randomized trials are needed to confirm benefits in later time windows.
