Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data

Román, Luís San; Menon, Bijoy K; Blasco, Jordi; Hernández‐Pérez, María; Dávalos, Antoni; Majoie, Charles B. L. M.; Campbell, Bruce; Guillemin, Françis; Lingsma, Hester F.; Anxionnat, René; Epstein, Jonathan; Saver, Jeffrey L.; Marquering, Henk A.; Wong, John H.; Lopes, Demetrius K.; Reimann, G; Desal, Hubert; Dippel, Diederik W.J.; Coutts, Shelagh B.; Rochemont, Richard du Mesnil de; Yavagal, Dileep R.; Ferré, J.-C.; Roos, Yvo B.W.E.M.; Liebeskind, David S; Lenthall, Robert; Molina, Carlos A.; Ajlan, Fahad S. Al; Reddy, Vivek; Dowlatshahi, Dar; Sourour, Nader‐Antoine; Oppenheim, Catherine; Mitha, Alim P.; Davis, Stephen M.; Weimar, Christian; Oostenbrugge, Robert J. van; Cobo, Erik; Kleinig, Timothy; Donnan, Geoffrey A.; Lugt, Aad van der; Demchuk, Andrew M.; Berkhemer, Olvert A.; Boers, Anna M. M.; Ford, Gary A.; Muir, Keith W.; Brown, Martin M.; Jovin, Tudor G; Zwam, Wim H. van; Mitchell, Peter; Hill, Michael D.; White, Phil; Bracard, Serge; Goyal, Mayank

doi:10.1016/s1474-4422(18)30242-4

Cited by 315 publications

(298 citation statements)

References 29 publications

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“…We previously reported that EVT may result in better functional independence in these patients with decreasing likelihood of benefit as stroke size increases and time progresses. In a recent HERMES (Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials) meta‐analysis assessing functional and safety outcomes based on baseline CT and MRI assessment, a significant improvement in functional outcomes was shown in patients with ASPECTS 3 to 5; however, an increase in symptomatic ICH was also found . Another HERMES meta‐analysis demonstrated improvement in outcomes with thrombectomy in patients with an ischemic core volume > 70ml .…”

Section: Discussionmentioning

confidence: 99%

“…In a recent HER-MES (Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials) meta-analysis assessing functional and safety outcomes based on baseline CT and MRI assessment, a significant improvement in functional outcomes was shown in patients with ASPECTS 3 to 5; however, an increase in symptomatic ICH was also found. 25 Another HERMES meta-analysis demonstrated improvement in outcomes with thrombectomy in patients with an ischemic core volume > 70ml. 26 However, there were imbalances in baseline characteristics that could not be adjusted for due to the limited sample size.…”

Section: Discussionmentioning

confidence: 99%

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Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection

Sarraj¹,

Hassan

Grotta³

et al. 2020

Annals of Neurology

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Objective The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are noncontrast computed tomography (CT) and CT perfusion (CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes. Methods A phase 2, multicenter, prospective cohort study of large‐vessel occlusions presented up to 24 hours from last known well was conducted. Patients received a unified prespecified imaging evaluation (CT, CT angiography, and CTP with Rapid Processing of Perfusion and Diffusion software mismatch determination). The treatment decision, EVT versus medical management, was nonrandomized and at the treating physicians’ discretion. An independent, blinded, neuroimaging core laboratory adjudicated favorable profiles based on predefined criteria (CT:Alberta Stroke Program Early CT Score ≥ 6, CTP:regional cerebral blood flow (<30%) < 70ml with mismatch ratio ≥ 1.2 and mismatch volume ≥ 10ml). Results Of 4,722 patients screened from January 2016 to February 2018, 361 patients were included. Two hundred eighty‐five (79%) received EVT, of whom 87.0% had favorable CTs, 91% favorable CTPs, 81% both favorable profiles, 16% discordant, and 3% both unfavorable. Favorable profiles on the 2 modalities correlated similarly with 90‐day functional independence rates (favorable CT = 56% vs favorable CTP = 57%, adjusted odds ratio [aOR] = 1.91, 95% confidence interval [CI] = 0.40–9.01, p = 0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR = 3.97, 95% CI = 1.97–8.01, p < 0.001). Fifty‐eight percent of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable (p < 0.001 for trend). In favorable CT/unfavorable CTP profiles, EVT was associated with high symptomatic intracranial hemorrhage (sICH) (24%) and mortality (53%) rates. Interpretation Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates, but those with an unfavorable CTP had higher adverse outcomes. Ann Neurol 2020;87:419–433

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection

Sarraj¹,

Hassan

Grotta³

et al. 2020

Annals of Neurology

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“…The latest HERMES collaboration analysis based on individual patient data from RCTs (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, THRACE, and PISTE) showed that thrombectomy led to better clinical outcomes at 90 days across a broad range of imaging categories, including ASPECTS <6 (OR=1.58 for ASPECTS 5–7 and OR=2.15 for ASPECTS 0–4) and infarcts affecting >1/3 of MCA territory (OR 1.7), supporting the value of thrombectomy in some patients with large infarcts at baseline 28. However, thrombectomy in patients with such unfavorable imaging profiles had higher rates of symptomatic intracranial hemorrhage than in the control group.…”

Section: Indications For Thrombectomymentioning

confidence: 80%

Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee

Mokin

Ansari

McTaggart

et al. 2019

J NeuroIntervent Surg

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“…Of 485 enrolled patients in the overall BEST study, 177 underwent CTP and were included in the analyses. The median age was 69 years (interquartile range [IQR]: 57-81), 87 were female (49%), with a median baseline NIHSS of 17 (IQR: [11][12][13][14][15][16][17][18][19][20]. Seventy-two patients (41%) presented in the early window.…”

Section: Resultsmentioning

confidence: 99%

“…Additionally, according to data from the HERMES collaboration, the benefit of thrombectomy persisted among patients whose ASPECTS score was 6‐8 (cOR: 2.34, 95% CI: 1.68‐3.26 for a shift in 90‐day mRS) but was absent if the baseline ASPECTS was 0‐5 (cOR: 1.24, 95% CI: .62‐2.49) . In a subsequent meta‐analysis, including two additional randomized clinical trials, the benefit of early window thrombectomy over medical therapy persisted despite ASPECTS of 0‐4 (cOR: 2.15, 95% CI: 1.06‐4.37) . While these patients also experienced higher rates of sICH with intervention (OR: 5.00, 95% CI: 1.30‐19.25), there was no significant increase in mortality (OR: .81, 95% CI: .36‐1.81).…”

Section: Discussionmentioning

confidence: 99%

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

Siegler

Messé

Sucharew

et al. 2019

Journal of Neuroimaging

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BACKGROUND AND PURPOSE The 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN). METHODS From a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0–24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time. RESULTS Of 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57‐81], 49% female, median ASPECTS 8 [IQR: 6‐9], median core 10 cc [IQR: 0‐30]). ASPECTS and core volume moderately correlated (r = −.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91‐1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time. CONCLUSIONS In this multicenter prospective cohort of patients who underwent thrombectomy, one‐third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.

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Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data

Abstract: Medtronic.

Cited by 315 publications

References 29 publications

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection

Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

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