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Endovascular treatment in patients with large vessel occlusion: reduced mortality despite minimal penumbra

  • Interventional Neuroradiology
  • Published:
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Abstract

Purpose

In patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), endovascular treatment (EVT) is highly effective for emergency revascularization. However, data on functional outcome are lacking for patients, which show no or minimal mismatch between ischemic core and penumbra.

Methods

Forty-five patients with AIS due to LVO of the anterior circulation were retrospectively analyzed within 6 h since onset when administered to our department. In all patients, there was no relevant penumbra according to CT perfusion (CTP). Functional outcome, defined by the modified Rankin Scale (mRS) at 30 and 90 days, was analyzed according to LVO treatment (EVT versus non-EVT). Confounding was addressed by multivariable regression analyses.

Results

mRS values at 30 days (p = 0.002) and 90 days (p = 0.005) after AIS occurrence were significantly lower in patients who had received EVT. There was no significant difference regarding good functional outcome, as measured by mRS of 0–2 at 30 (p = 0.432) and 90 days, respectively (p = 0.186). Mortality was significantly reduced in patients undergoing EVT at 30-day (p < 0.001) and at 90-day follow-up (p = 0.003), respectively. Multivariable regression analyses revealed that EVT was associated with reduced mortality at 30 (OR 0.091; CI (0.013–0.612); p = 0.014) and 90 days (OR 0.134; CI (0.021–0.857); p = 0.034) after AIS.

Conclusions

Despite a small and highly selected patient collective, our study indicates that AIS patients with minimal penumbra in CTP might benefit from EVT in terms of reduced mortality at 30 and 90 days after AIS. However, in this group of patients, we could not prove favorable functional outcome at 30 and 90 days, despite receiving EVT.

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References

  1. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Davalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millan M, Davis SM, Roy D, Thornton J, Roman LS, Ribo M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731

    Article  Google Scholar 

  2. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, Millan M, Urra X, Cardona P, Lopez-Cancio E, Tomasello A, Castano C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Perez M, Goyal M, Demchuk AM, von Kummer R, Gallofre M, Davalos A (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306

    Article  CAS  Google Scholar 

  3. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, de Rochemont RD, Singer OC, Stent JR (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295

    Article  CAS  Google Scholar 

  4. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Nijeholt GJ LA, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20

    Article  Google Scholar 

  5. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018

    Article  CAS  Google Scholar 

  6. Abou-Chebl A (2010) Endovascular treatment of acute ischemic stroke may be safely performed with no time window limit in appropriately selected patients. Stroke 41:1996–2000

    Article  Google Scholar 

  7. Turk AS, Magarick JA, Frei D, Fargen KM, Chaudry I, Holmstedt CA, Nicholas J, Mocco J, Turner RD, Huddle D, Loy D, Bellon R, Dooley G, Adams R, Whaley M, Fanale C, Jauch E (2013) CT perfusion-guided patient selection for endovascular recanalization in acute ischemic stroke: a multicenter study. J Neurointervent Surg 5:523–527

    Article  Google Scholar 

  8. Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan MJ, Coutts SB, Demchuk AM, Goyal M, Aviv RI, Symons S, Gulka IB, Beletsky V, Pelz D, Hachinski V, Chan R, Lee TY (2006) Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusion-derived blood flow and blood volume measurements. Stroke 37:1771–1777

    Article  CAS  Google Scholar 

  9. Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D, Pineda C, Serena J, van der Schaaf I, Waaijer A, Anderson J, Nesbit G, Gabriely I, Medina V, Quiles A, Pohlman S, Quist M, Schnyder P, Bogousslavsky J, Dillon WP, Pedraza S (2006) Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 37:979–985

    Article  Google Scholar 

  10. von Baumgarten L, Thierfelder KM, Beyer SE, Baumann AB, Bollwein C, Janssen H, Reiser MF, Straube A, Sommer WH (2016) Early CT perfusion mismatch in acute stroke is not time-dependent but relies on collateralization grade. Neuroradiology 58:357–365

    Article  Google Scholar 

  11. Powers WJ, Grubb RL Jr, Raichle ME (1984) Physiological responses to focal cerebral ischemia in humans. Ann Neurol 16:546–552

    Article  CAS  Google Scholar 

  12. Kuschinsky W, Wahl M (1978) Local chemical and neurogenic regulation of cerebral vascular resistance. Physiol Rev 58:656–689

    Article  CAS  Google Scholar 

  13. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, Pereira VM, Mehta BP, Baxter BW, Abraham MG, Cardona P, Veznedaroglu E, Hellinger FR, Feng L, Kirmani JF, Lopes DK, Jankowitz BT, Frankel MR, Costalat V, Vora NA, Yoo AJ, Malik AM, Furlan AJ, Rubiera M, Aghaebrahim A, Olivot JM, Tekle WG, Shields R, Graves T, Lewis RJ, Smith WS, Liebeskind DS, Saver JL, Jovin TG (2018) Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378:11–21

    Article  Google Scholar 

  14. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, Sarraj A, Kasner SE, Ansari SA, Yeatts SD, Hamilton S, Mlynash M, Heit JJ, Zaharchuk G, Kim S, Carrozzella J, Palesch YY, Demchuk AM, Bammer R, Lavori PW, Broderick JP, Lansberg MG (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:708–718

    Article  Google Scholar 

  15. Hill MD, Demchuk AM, Goyal M, Jovin TG, Foster LD, Tomsick TA, von Kummer R, Yeatts SD, Palesch YY, Broderick JP (2014) Alberta Stroke Program early computed tomography score to select patients for endovascular treatment: Interventional Management of Stroke (IMS)-III Trial. Stroke 45:444–449

    Article  Google Scholar 

  16. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL (2018) 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110

    Article  Google Scholar 

  17. Mokin M, Snyder KV, Siddiqui AH, Levy EI, Hopkins LN (2016) Recent endovascular stroke trials and their impact on stroke systems of care. J Am Coll Cardiol 67:2645–2655

    Article  Google Scholar 

  18. Tsogkas I, Knauth M, Schregel K, Behme D, Wasser K, Maier I, Liman J, Psychogios MN (2016) Added value of CT perfusion compared to CT angiography in predicting clinical outcomes of stroke patients treated with mechanical thrombectomy. Eur Radiol 26:4213–4219

    Article  Google Scholar 

  19. Lee TY, Murphy BD, Aviv RI, Fox AJ, Black SE, Sahlas DJ, Symons S, Lee DH, Pelz D, Gulka IB, Chan R, Beletsky V, Hachinski V, Hogan MJ, Goyal M, Demchuk AM, Coutts SB (2006) Cerebral blood flow threshold of ischemic penumbra and infarct core in acute ischemic stroke: a systematic review. Stroke 37:2201 author reply 2203

    Article  Google Scholar 

  20. Lev MH, Segal AZ, Farkas J, Hossain ST, Putman C, Hunter GJ, Budzik R, Harris GJ, Buonanno FS, Ezzeddine MA, Chang Y, Koroshetz WJ, Gonzalez RG, Schwamm LH (2001) Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke 32:2021–2028

    Article  CAS  Google Scholar 

  21. Warach S, Al-Rawi Y, Furlan AJ, Fiebach JB, Wintermark M, Lindsten A, Smyej J, Bharucha DB, Pedraza S, Rowley HA (2012) Refinement of the magnetic resonance diffusion-perfusion mismatch concept for thrombolytic patient selection: insights from the desmoteplase in acute stroke trials. Stroke 43:2313–2318

    Article  Google Scholar 

  22. Huang X, Yang Q, Shi X, Xu X, Ge L, Ding X, Zhou Z (2019) Predictors of malignant brain edema after mechanical thrombectomy for acute ischemic stroke. J Neurointervent Surg neurintsurg-2018-014650

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Authors and Affiliations

  1. Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany

    Philip Hoelter, Manuel Schmidt, Lorenz Breuer, Bernd Kallmünzer, Stefan Schwab, Arnd Doerfler & Tobias Engelhorn

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  1. Philip Hoelter
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  2. Manuel Schmidt
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  3. Lorenz Breuer
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  4. Bernd Kallmünzer
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  5. Stefan Schwab
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Correspondence to Philip Hoelter.

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Hoelter, P., Schmidt, M., Breuer, L. et al. Endovascular treatment in patients with large vessel occlusion: reduced mortality despite minimal penumbra. Neuroradiology 61, 1469–1476 (2019). https://doi.org/10.1007/s00234-019-02280-3

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  • DOI: https://doi.org/10.1007/s00234-019-02280-3

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