Association of Noncontrast Computed Tomography and Perfusion Modalities With Outcomes in Patients Undergoing Late-Window Stroke Thrombectomy

Abstract

ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).Design, Setting, and ParticipantsIn this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022.ExposuresSelection by NCCT, CTP, or DWI.Main Outcomes and MeasuresPrimary outcome was functional independence (modified Rankin scale 0-2) at 90 days.ResultsAmong 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups.Conclusions and RelevanceIn this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy

“…There were comparable rates of sICH between the 2 groups (OR 1.09, 95% CI 0.58–2.04; p = 0.80); however, there was significant heterogeneity noted among studies ( I 2 = 67%, p = 0.017) (Figure 4). On removal of the outlier study, 5 the results still yielded comparable rates of sICH between the 2 groups (OR 0.76, 95% CI 0.52–1.10; p = 0.15) (eFigures 3 and 4, links.lww.com/WNL/C725).…”

“…5 Dekker et al reported data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) database, a multicenter, prospectively maintained registry. ASPECTS were comparable between CTP-selected patients (median 7, IQR 7 Nguyen et al 6 Nogueira et al 4 Porto et al 5 Dekker et al 8 Comparison and NCCT-selected patients (median 9, IQR 7-10). Patients with anterior circulation large vessel (intracranial carotid artery, middle cerebral artery M1/M2 segment, or anterior cerebral artery A1/A2 segment) occlusion and TLSW or symptom onset to arterial puncture of beyond 6.5 hours were included.…”

“…Patients with NIHSS score of 6 or higher, pre-stroke mRS of 0–2, anterior circulation large vessel (internal carotid artery, middle cerebral artery M1/M2 segment) occlusion, and TLSW to arterial puncture of 6–24 hours were included. 5…”

“…Patients with NIHSS score of 6 or higher, pre-stroke mRS of 0-2, anterior circulation large vessel (internal carotid artery, middle cerebral artery M1/M2 segment) occlusion, and TLSW to arterial puncture of 6-24 hours were included. 5 Dekker et al reported data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) database, a multicenter, prospectively maintained registry. ASPECTS were comparable between CTP-selected patients (median 7, IQR 7 Nguyen et al 6 Nogueira et al 4 Porto et al 5 Dekker et al 8 Comparison and NCCT-selected patients (median 9, IQR 7-10).…”

“…Several recent studies have attempted to compare CTP and NCCT for EVT selection in late-window AIS-LVO patients, but these studies have shown varying results. [4][5][6][7][8] Therefore, we conducted a systematic review and meta-analysis to compare clinical outcomes between patients with AIS-LVO treated by EVT after CTP and NCCT imaging evaluation.…”