CT perfusion-guided patient selection for endovascular treatment of acute ischemic stroke is safe and effective

Abstract

Background Traditional treatment in acute ischemic stroke is based on time criteria when administering intravenous and intra-arterial therapies. However, recent evidence suggests that image-based criteria may be useful for selecting patients for intra-arterial interventions. The use of CT perfusion (CTP)-based criteria, regardless of time from symptom onset, in patient selection for intra-arterial treatment of ischemic stroke was assessed. Methods Patients with ischemic stroke who presented to the emergency department at the Medical University of South Carolina with a National Institute of Health Stroke Scale score of $ 8, regardless of time from symptom onset, were assessed retrospectively. CTP maps were qualitatively assessed for the presence of penumbra and infarction. Selected patients underwent mechanical aspiration of their occlusion using the Penumbra system. Functional outcome was then recorded using the modified Rankin scale (mRS) at 90 days or the closest follow-up to 90 days. Results 53 patients were included in the study. The median time from symptom onset to groin vascular access was 6.3 h. Eight patients (15%) had bleeding complications including subarachnoid hemorrhage, parenchymal hemorrhage and intraventricular hemorrhage. After CTP-based selection, the patients were divided into two groups for analysis: #6 h and >6 h from symptom onset to endovascular procedure. No difference was found in functional outcome between the two groups (38.5% and 40.7% achieved 90-day mRS #2, respectively (p¼1.0) and 57.7% and 51.9% achieved 90-day mRS #3, respectively (p¼0.785)). There was no difference in the rate of intracranial hemorrhage between the two groups (11.5 vs 18.5, p¼0.704). Conclusion This study demonstrated similar rates of good functional outcome and intracranial hemorrhage in patients with ischemic stroke when endovascular treatment was performed based on CTP selection rather than time-guided selection. These findings suggest that endovascular reperfusion in ischemic stroke may be effective and safe, and may allow patient selection not solely based on time from symptom onset. BACKGROUND

Can CT Perfusion Guide Patient Selection for Treatment of Delayed Cerebral Ischemia?

“…In recent years, it is becoming more apparent that image-based criteria may have a role in patient selection for treatment of acute stroke. Turk et al reported similar rates of good functional outcome and low rates of intracranial hemorrhage when endovascular treatment was performed based on CTP rather than time-guided selection [17,18]. This potential for image-based criteria may also have a role in aneurysmal SAH, particularly in patients with limited clinical examination, uncertain clinical findings, or discrepant clinical and imaging data.…”

A Novel Technique for the Measurement of CBF and CBV with Robot-Arm-Mounted Flat Panel CT in a Large-Animal Model

“…Additionally, several works indicate that interventional recanalization might be beneficial in patients presenting outside the therapeutic window accepted for IV thrombolysis. 18,19 However, this relatively new treatment option has drawbacks as well. One is the invasive nature of the procedure with the risk of severe or fatal complications.…”

Intracerebral hemorrhage secondary to intravenous and endovascular intraarterial revascularization therapies in acute ischemic stroke: an update on risk factors, predictors, and management

“…A real-world experience with patient selection for endovascular therapy on the basis of CT perfusion findings shows a similar rate of ICH in those who had favorable CT perfusion findings irrespective of time constraints and those who had time-guided selection (0-6 hours from symptom onset to endovascular procedure). 47 This suggests that in properly selected patients, ischemic stroke can be safely treated beyond the current recommended time intervals without significantly increasing the rate of hemorrhagic complications.…”

“…In patients with malignant MCA strokes, 3 24,27,47 However, patients who received IV thrombolysis or had hemorrhagic transformation resulting in a large parenchymal hematoma were excluded from enrollment in all three trials.…”