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Published on: September 25, 2016
Association of initial imaging modality and futile recanalization after thrombectomy
Thomas Raphael Meinel1, Johannes Kaesmacher1, Pascal John Mosimann1
1From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada.
Objective:
To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064).
Methods:
In 2,011 patients (49.7% female, median age 73 years [61-81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4-6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5-6 as futile.
Results:
MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677-1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4-6 including 393/1,489 (26%) FR mRS 5-6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%-47%] vs 29% [25%-32%], p < 0.001; aOR 1.77 [95% CI 1.25-2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT.
Conclusions:
CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
Insights
Selecting patients for mechanical thrombectomy using CT scans, rather than MRI, is linked to a higher rate of futile recanalizations. MRI selection shows better functional outcomes and lower mortality, despite longer workflow times.
Area of Science:
- Neurology
- Radiology
- Interventional Medicine
Background:
- Mechanical thrombectomy (MT) is a key treatment for acute ischemic stroke.
- Patient selection for MT based on initial imaging modality (MRI vs. CT) may influence treatment outcomes.
- Futile recanalization (FR) is a significant concern, defined as poor functional outcome despite successful reperfusion.
Purpose of the Study:
- To investigate the association between the initial imaging modality (MRI vs. CT) used for patient selection and the rate of futile recanalizations (FRs) after mechanical thrombectomy (MT).
Main Methods:
- A multicenter, retrospective observational registry (BEYOND-SWIFT) including 2,011 patients treated between 2009 and 2017.
- Univariate and multivariate analyses were performed to assess the occurrence of FRs, defined as 90-day modified Rankin Scale (mRS) scores of 4-6.
- Sensitivity analysis considered patients with mRS 5-6 as futile.
Main Results:
- CT-based selection was associated with significantly higher rates of FRs (44%) compared to MRI-based selection (29%) (p < 0.001).
- Adjusted odds ratio (aOR) for FR was 1.77 (95% CI 1.25-2.51) for CT selection versus MRI selection.
- MRI-selected patients experienced approximately 30-minute workflow delays but showed more favorable functional outcomes and mortality.
Conclusions:
- CT selection for MT is linked to an increased risk of futile recanalizations compared to MRI selection.
- Strategies to reduce workflow delays in MRI-based selection are necessary.
- Further research is required to understand the impact of initial imaging modality on FR and to develop predictive algorithms.
