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Elevated Tmax >4 Seconds Volume Predicts Worse Functional Outcome Following Endovascular Treatment in M2 Middle
Iman Kiani1, Alireza Kooshki1, Hamza Adel Salim1
1From the Students' Scientific Research Center (I.K.), Tehran University of Medical Sciences, Tehran, Iran; Student Research Committee (A.K.), Birjand University of Medical Sciences, Birjand, 9717853076, Iran; Department of Radiology (H.A.S., D.L., A.C., D.T., V.Y.), Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA; Department of Neuroradiology (H.A.S., M.A.B.), MD Anderson Medical Center, Houston, TX 77030, USA; Department of Neuroradiology (D.L.), Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26505; Department of Neurosurgery and Interventional Neuroradiology (N.A.), Louisiana State University, LA; Nuffield Department of Surgical Sciences (Y.-L.L., A.A.D.), Medical Sciences Division, Oxford Centre for Clinical Magnetic Resonance (OCMR) (F.Z., J.T.G., A.A.D.), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab (M.A.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Interventional Radiology (M.C.), Oregon Health and Science University, Portland, OR 97239, USA; Departments of Radiology & Neurology (T.N.N.), Boston Medical Center, Boston, MA, USA; Department of Interventional Neuroradiology (G.W.A., J.J.H.), Stanford Medical Center, Palo Alto, California, USA; UCLA Stroke Center and Department of Neurology Department (D.S.L.), UCLA, Los Angeles, California, USA; Department of Radiology (T.D.F.), Neuroendovascular Program, University Medical Center Münster, Germany; Department of Diagnostic and Interventional Neuroradiology (A.G.), Erasme University Hospital, Brussels, Belgium; Department of Neuroradiology (A.A.D.), Queens Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK; Neuroendovascular Program (A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA and Neurointerventional & Neuroanalytics Consortium (NAN-C) (A.A.D.), Department of Hospital & Institutional Care, School of Medicine, Toronto Metropolitan University, Toronto, ON.
Background And Purpose:
Acute ischemic stroke (AIS) due to M2 middle cerebral artery (MCA) occlusion represents the most frequent medium vessel occlusion (MeVO), yet the benefit of EVT in these patients remains uncertain. The perfusion parameter Tmax >4 seconds reflects delayed contrast arrival and captures regions of hemodynamic compromise that may include both potentially salvageable tissue and areas at risk of infarction if reperfusion is delayed or incomplete. This study therefore aims to evaluate whether the Tmax > 4s volume perfusion deficit predicts functional outcomes in patients with M2 occlusions who undergo EVT.
Materials And Methods:
For this retrospective multinational study, AIS patients with M2 MCA occlusion who underwent EVT were included. We performed univariable and multivariable logistic regression analysis to predict the mRS outcomes 90 days after the stroke (90-day mRS), based on the Tmax > 4s volume and adjusting for age, admission NIHSS, ASPECTS, intravenous thrombolysis (IVT), and modified thrombolysis in cerebral infarction grading (mTICI).
Results:
130 M2 AIS patients were included, with a median age of 75.5 (65-81.75). The model based on Tmax > 4s volume had an area under the curve (AUC) of 0.81 (95% CI, 0.73-0.88). The optimal Tmax >4s volume threshold was 113 mL, which demonstrated the highest performance for discriminating between outcomes. Among the participants, ASPECTS (p = 0.03) was significantly lower and 90-day mRS (p = 0.05) was significantly higher in the Tmax > 4s greater than 113 ml volume patient cohort. In the multivariable logistic regression analysis, higher Tmax > 4s volume (OR: 0.24; 95% CI: 0.08-0.70) and higher admission NIHSS (OR: 0.88; 95% CI: 0.81-0.96) were independently associated with lower odds of favorable outcome (mRS 0-2), while successful EVT was a protective factor (OR: 6.10; 95% CI: 1.80-20.64).
Conclusions:
Our results demonstrate that Tmax > 4s serves as a quantitative marker for predicting mRS outcomes in M2 AIS patients who underwent EVT. When considered alongside established clinical variables, this metric may provide complementary prognostic information.
Insights
The Tmax > 4s volume effectively predicts outcomes for acute ischemic stroke patients with M2 middle cerebral artery occlusions undergoing endovascular therapy. This perfusion parameter offers valuable prognostic information alongside clinical factors.
Area of Science:
- Neurology
- Radiology
- Stroke Medicine
Background:
- M2 middle cerebral artery (MCA) occlusions are the most common medium vessel occlusions in acute ischemic stroke (AIS).
- The efficacy of endovascular therapy (EVT) for M2 occlusions is not fully established.
- The Tmax > 4s perfusion parameter indicates hemodynamic compromise and potentially salvageable brain tissue.
Purpose of the Study:
- To evaluate the predictive value of Tmax > 4s volume for functional outcomes in AIS patients with M2 occlusions undergoing EVT.
- To determine if Tmax > 4s volume can improve prognostication in this patient group.
Main Methods:
- Retrospective multinational study including AIS patients with M2 MCA occlusion treated with EVT.
- Univariable and multivariable logistic regression analyses were used to predict 90-day modified Rankin Scale (mRS) outcomes.
- Analysis adjusted for age, NIHSS, ASPECTS, IVT, and mTICI, focusing on Tmax > 4s volume.
Main Results:
- 130 patients were included; the Tmax > 4s volume model showed an AUC of 0.81.
- An optimal Tmax > 4s volume threshold of 113 mL was identified.
- Higher Tmax > 4s volume and NIHSS were associated with poorer outcomes, while successful EVT was protective.
Conclusions:
- Tmax > 4s volume is a quantitative marker for predicting functional outcomes (mRS) in M2 AIS patients treated with EVT.
- This perfusion metric provides complementary prognostic information when used with established clinical variables.
