Magnetic Resonance Imaging of Cerebrovascular Diseases

Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well

“…A pooled analysis of latewindow trials (AURORA) demonstrated an association of mismatch profile with EVT outcomes. 8 In the current study, patients with a perfusion imaging mismatch had significantly better clinical outcomes when treated with EVT, with almost 4 times the odds of functional independence. Significant differences in baseline clinical and imaging characteristics between patients receiving EVT vs medical management in nomismatch subgroup remain a caveat and may have resulted in the higher functional independence rates associated with EVT.…”

“…Proportions of patients with wake-up stroke (EVT, 31 of 153 [20%], vs control, 22 of 111 [20%]; P = .93) were similar between the 2 treatment groups. However, patients receiving EVT demonstrated lower stroke severity (median [IQR] NIHSS score in EVT group, 14 [8][9][10][11][12][13][14][15][16][17][18][19][20], vs control, 17 [10-21.5]; P = .01) and earlier arrival to an EVT-capable center (median [IQR] time in EVT group, 28.1 [24.5-38.2], vs control, 31.4 hours [25.8-47.2]; P = .002). Intravenous thrombolysis was administered in 7 of 184 patients (4%) in the EVT group and 6 of 116 patients (5%) receiving medical management (P = .57), likely a combination of off-label administration and administration under wake-up stroke protocols.…”

“…The CT ASPECTS at each EVT center was available for 247 patients (82%), 144 patients (58%) receiving EVT and 103 (42%) medical management, whereas perfusion imaging parameters were available for 187 patients (62%), 132 patients (71%) receiving EVT and 55 (29%) receiving medical management. Estimates of ischemic injury were smaller in the EVT group; on noncontrast CT (median [IQR] CT ASPECTS for those receiving EVT, 7 [6][7][8][9], vs control, 5 [3][4][5][6][7]; P < .001) and CT perfusion (median [IQR] ischemic core volume for EVT, 4 mL [0-14.5], vs control, 13.4 mL [0-69] mL; P = .004). However, critically hypoperfused tissue volumes (Tmax >6 seconds) were similar on perfusion imaging (median [IQR] volume, EVT, 79 mL [51.5-148.5], vs control, 91 mL [52-155]; P = .43).…”

“…[1][2][3][4][5] The DAWN and DEFUSE 3 trials, along with the subsequent AURORA meta-analysis, extended the therapeutic time window to 24 hours. [6][7][8] Currently, guidelines from the American Heart Association/American Stroke Association and the European Stroke Association provide class 1 recommendations for the use of EVT in selected patients with ischemic stroke due to large-vessel occlusions up to 24 hours. 9,10 However, no randomized trial evidence exists for EVT efficacy and safety beyond 24 hours of last known well.…”

Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke: An Evolution of Trials

“…57 Despite the high reperfusion rate achieved with EVT for LVO stroke, excellent functional outcome (mRS scores: 0-1) was observed in only 27% of cases according to HERMES, 7 which is comparable to 28.2% from the AURORA meta-analysis. 6, 58 The Chemical Optimization of Cerebral Embolectomy (CHOICE) trial was conducted to assess the efficacy and safety of adjunct intra-arterial alteplase treatment compared with placebo in patients with LVO acute stroke treated with EVT that resulted in successful reperfusion on angiography, defined as TICI-2b50, indicating reperfusion in 50% or greater of the occluded territory. 59 Patients had a greater likelihood of full neurological recovery (mRS: 0-1) if they were treated with intra-arterial alteplase compared with placebo following the procedure (59 vs. 40.4%; p ¼ 0.47).…”