How Do Patient Outcomes in Mechanical Thrombectomy for Large-Core Stroke Vary Based on Neuroimaging Modalities Used...

Area of Science:

• Neurology
• Radiology
• Interventional Cardiology

Background:

• The optimal imaging modality for selecting patients with large-core acute ischemic stroke (AIS) for endovascular thrombectomy (EVT) remains debated.
• Non-contrast CT (NCCT), CT perfusion (CTP), and diffusion-weighted imaging (DWI) are used, each with potential benefits in assessing infarct core and penumbra.

Purpose of the Study:

• To compare clinical outcomes of AIS patients with large ischemic cores undergoing EVT who were triaged using NCCT alone versus those triaged with CTP or DWI in addition to NCCT.
• To evaluate if advanced imaging modalities influence procedural success and functional status post-EVT.

Main Methods:

• A retrospective analysis of the Stroke Thrombectomy and Aneurysm Registry (STAR) database (2014-2023) including 403 patients with anterior-circulation AIS and large core (ASPECTS < 6) undergoing EVT.
• Patients were stratified by pre-EVT imaging: NCCT alone, NCCT + CTP, or NCCT + DWI.
• Propensity score matching (PSM) was used to create balanced cohorts for comparing NCCT vs. CTP and NCCT vs. DWI.

Main Results:

• Before PSM, functional outcomes (90-day mRS 0-3), reperfusion rates (mTICI ≥ 2B), and symptomatic intracranial hemorrhage (sICH) rates were similar across groups.
• DWI showed higher mTICI ≥ 2C rates (50.9%) compared to NCCT (41.3%) and CTP (27.8%). CTP group had the highest ICH incidence (44.1%).
• After 1:1 PSM, no significant differences were observed in functional outcomes (90-day mRS 0-3), reperfusion (mTICI ≥ 2C), ICH rates, or sICH rates between NCCT and advanced imaging groups.

Conclusions:

• In patients with large-vessel occlusion AIS and low ASPECTS, selecting for EVT based on NCCT alone or with advanced imaging does not significantly alter procedural or functional outcomes.
• NCCT may be sufficient for EVT selection in this population, particularly in resource-constrained environments.
• Advanced imaging modalities did not demonstrate a significant benefit in improving patient outcomes despite potential differences in reperfusion or hemorrhage rates pre-PSM.