Late Endovascular Revascularization in Acute Ischemic Stroke Based on Clinical-Diffusion Mismatch

Janjua, Nazli; El-Gengaihy, A; Pile‐Spellman, John; Qureshi, Adnan I.

doi:10.3174/ajnr.a1474

Cited by 35 publications

(20 citation statements)

References 20 publications

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“…Utilizing diffusion-weighted MR imaging, and not CT perfusion, to identify potential candidates for endovascular intervention, Janjua et al 29 were still able to show benefit from intervention in patients presenting more than 8 hours after the onset of stroke symptoms. The authors reported a decrease in the NIHSS score of more than 4 points in 72% of the patients selected for intervention.…”

Section: Perfusion-based Identification Of Endovascular Candidates: Lmentioning

confidence: 99%

Computed tomography perfusion–based selection of patients for endovascular recanalization

Amenta

Ali

Dumont

et al. 2011

FOC

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Intravenous and intraarterial recombinant tissue plasminogen activator remains underutilized in the treatment of acute ischemic stroke, largely due to strict adherence to the concept of the therapeutic time window for administration. Recent efforts to expand the number of patients eligible for thrombolysis have been mirrored by an evolution in endovascular recanalization technology and techniques. As a result, there is a growing need to establish efficient and reliable means by which to select candidates for endovascular intervention beyond the traditional criteria of time from symptom onset. Perfusion imaging techniques, particularly CT perfusion used in combination with CT angiography, represent an increasingly recognized means by which to identify those patients who stand to benefit most from endovascular recanalization. Additionally, CT perfusion and CT angiography appear to provide sufficient data by which to exclude patients in whom there is little chance of neurological recovery or a substantial risk of postprocedure symptomatic intracranial hemorrhage. The authors review the current literature as it pertains to the limitations of time-based selection of patients for intervention, the increasing utilization of endovascular therapy, and the development of a CT perfusion-based selection of acute stroke patients for endovascular recanalization. Future endeavors must prospectively evaluate the utility and safety of CT perfusion-based selection of candidates for endovascular intervention.

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Section: Perfusion-based Identification Of Endovascular Candidates: Lmentioning

confidence: 99%

Computed tomography perfusion–based selection of patients for endovascular recanalization

Amenta

Ali

Dumont

et al. 2011

FOC

View full text Add to dashboard Cite

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“…This has been studied retrospectively among patients presenting beyond 8 hours who have undergone endovascular therapy. 33 An additional study applied the ASPECTS 25 to brain DWI in nonlacunar anterior circulation infarction and also demonstrated a similar phenomenon of early neurologic deterioration and infarct expansion among patients with initial NIHSS score Ն8 and ASPECTS Ն8.…”

Section: Purposes Of Imaging In Ais Patients Beyond 8 Hours: Predictimentioning

confidence: 99%

“…39 Other case series of imagingguided endovascular treatment beyond 8 hours have been published, 40 -42 including those studies serving as pilots for planned future clinical trials. 33,41 DISCUSSION Effective radiologic screening for AIS patients beyond 8 hours requires accuracy to identify potential benefit and harm of treatment. With use of perfusion imaging parameters to identify areas of infarction and ischemia, time windows become less rigid and more patient-specific.…”

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Use of neuroimaging to guide the treatment of patients beyond the 8-hour time window

Janjua

2012

Neurology

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Revascularization time windows for patients with acute ischemic stroke are generally restricted to 8 hours. Later treatment attempts require more accurate prediction of risk and benefit, as safety and efficacy at these time strata are less well demonstrated. Advanced imaging techniques identify irreversible infarction as well as tissue at risk. Diffusion-weighted MRI detects ischemia within minutes of onset, whereas perfusion-weighted MRI and CT perfusion studies disclose the ischemic penumbra. Combined, they provide information on mismatched tissuepotentially salvageable brain. In addition, noninvasive angiography is a useful adjunct to localize arterial occlusion. Neurology

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“…In a small study of 11 patients presenting beyond 8 hours of symptom onset who had ICM and underwent ET, a decrease in the NIH Stroke Scale score Ͼ4 points was achieved in 72% of the subjects without sICH. 35 The added value in MRI triage of AIS is the potential of excluding patients who have stroke mimics Patient presenting with acute onset of global aphasia and right hemiparesis…”

Section: Figurementioning

confidence: 99%

Application of acute stroke imaging

Shang

Yavagal

2012

Neurology

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Due to the dynamic and versatile characteristics of ischemic penumbra, selecting the right acute ischemic stroke (AIS) patients for revascularization therapy (RT) based on initial available imaging can be challenging. The main patient selection criterion for RT is the size of the mismatch between the potentially salvageable tissue (penumbra) and the irreversibly damaged tissue (core). The goal of revascularization RT is to "freeze" the core and prevent it from extending to the penumbral tissue. Penumbral imaging selection of AIS patients for RT, using magnetic resonance or CTbased studies, may provide more clinical benefit to the appropriate patients, although direct evidence is pending. Not all penumbra-core mismatches beyond 3 hours are equal and need treatment, and defining which mismatches to target for RT is the current goal of ongoing clinical trials. In addition to "penumbral"-based imaging, large vessel occlusion and clot length estimation based on CT angiography and noncontrasted ultrathin CT scan has been used to identify patients who are refractory to systemic thrombolysis and may be eligible for endovascular therapy. The application of various imaging modalities in selecting and triaging AIS patients for RT is discussed in this review. Larger prospective randomized trials are needed to better understand the role of various imaging modalities in selecting AIS patients for RT and to understand its influence on clinical outcome. Neurology Although acute ischemic stroke (AIS) is the leading cause of disability worldwide, treatment options for AIS remain limited to systemic and local revascularization therapies. Currently, the only US Food and Drug Administration-approved treatment for AIS is IV recombinant tissue plasminogen activator (rtPA), which must be administered within 3 hours of symptom onset. 1Results from the ECASS III trial have since expanded treatment to 4.5 hours; however, the majority of AIS patients still do not receive IV rtPA because of this narrow time window.2 Endovascular therapy (ET) may be considered for AIS patients for whom IV rtPA fails, who do not qualify for IV rtPA treatment, or who present beyond the IV rtPA time window. Despite the relatively high reported recanalization rate of ET (48% to 87%), good clinical outcome is limited to 25% to 41%. [3][4][5][6][7][8][9] One possible explanation of the discrepancy between recanalization and clinical outcome rates is the presence of variable sizes of salvageable brain tissue (penumbra) in the ischemic territory. Penumbra-based imaging, large-vessel occlusion, and clot length estimation based on CT angiography (CTA) and ultrathin noncontrasted CT (NCCT) head scanning have been used to identify patients who are refractory to systemic thrombolysis and may be appropriate for ET, thus potentially improving clinical outcome. Selecting patients on the basis of vessel occlusion and clot length is the main target for an ongoing clinical trial,

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Late Endovascular Revascularization in Acute Ischemic Stroke Based on Clinical-Diffusion Mismatch

Cited by 35 publications

References 20 publications

Computed tomography perfusion–based selection of patients for endovascular recanalization

Computed tomography perfusion–based selection of patients for endovascular recanalization

Use of neuroimaging to guide the treatment of patients beyond the 8-hour time window

Application of acute stroke imaging

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