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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Value of Computed Tomographic Perfusion-Based Patient Selection for Intra-Arterial Acute Ischemic Stroke Treatment
Jordi Borst1, Olvert A Berkhemer2, Yvo B W E M Roos2
1From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of Public Health (H.F.L.), Radiology (A.v.d.L.), and Neurology (O.A.B., D.W.J.D.), Erasmus MC, University Medical Center Rotterdam, The Netherlands; and Department of Radiology, Texas Stroke Institute, Plano, TX (A.J.Y.). j.borst@amc.uva.nl.
Insights
Computed tomographic perfusion (CTP) can predict outcomes in acute ischemic stroke patients. However, CTP cannot reliably identify individuals who will not benefit from intra-arterial therapy.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Randomized trials have not yet proven the utility of computed tomographic perfusion (CTP) for patient selection in intra-arterial treatment of acute ischemic stroke.
- Further investigation is needed in a cohort not pre-selected using CTP.
Purpose of the Study:
- To investigate the relationship between CTP-derived parameters and patient outcomes.
- To assess the treatment effect of intra-arterial therapy in relation to CTP-derived parameters in patients with acute ischemic stroke due to proximal intracranial arterial occlusion.
Main Methods:
- Utilized data from 175 patients who underwent CTP in the MR CLEAN trial.
- Employed multivariable ordinal logistic regression to associate CTP parameters (ischemic core, penumbra, percentage ischemic core) with functional outcome (modified Rankin Scale).
- Examined interactions between CTP parameters, mismatch, and treatment effect.
Main Results:
- A larger ischemic core volume and percentage ischemic core were associated with poorer functional outcomes (OR 0.79 per 10 mL, P<0.001; OR 0.82 per 10%, P=0.002).
- Penumbra volume did not show a significant association with functional outcome (OR 0.97 per 10 mL, P=0.15).
- No significant interaction was found between CTP-derived parameters or mismatch and the treatment effect.
Conclusions:
- CTP is a valuable tool for predicting functional outcomes in acute ischemic stroke patients.
- CTP cannot reliably identify patients who are unlikely to benefit from intra-arterial therapy.
Background And Purpose:
The utility of computed tomographic perfusion (CTP)-based patient selection for intra-arterial treatment of acute ischemic stroke has not been proven in randomized trials and requires further study in a cohort that was not selected based on CTP. Our objective was to study the relationship between CTP-derived parameters and outcome and treatment effect in patients with acute ischemic stroke because of a proximal intracranial arterial occlusion.
Methods:
We included 175 patients who underwent CTP in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN). Association of CTP-derived parameters (ischemic-core volume, penumbra volume, and percentage ischemic core) with outcome was estimated with multivariable ordinal logistic regression as an adjusted odds ratio for a shift in the direction of a better outcome on the modified Rankin Scale. Interaction between CTP-derived parameters and treatment effect was determined using multivariable ordinal logistic regression. Interaction with treatment effect was also tested for mismatch (core <70 mL; penumbra core >1.2; penumbra core >10 mL).
Results:
The adjusted odds ratio for improved functional outcome for ischemic core, percentage ischemic core, and penumbra were 0.79 per 10 mL (95% confidence interval: 0.71-0.89; P<0.001), 0.82 per 10% (95% confidence interval: 0.66-0.90; P=0.002), and 0.97 per 10 mL (96% confidence interval: 0.92-1.01; P=0.15), respectively. No significant interaction between any of the CTP-derived parameters and treatment effect was observed. We observed no significant interaction between mismatch and treatment effect.
Conclusions:
CTP seems useful for predicting functional outcome, but cannot reliably identify patients who will not benefit from intra-arterial therapy.
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