title: Reperfusion by combined thrombolysis and mechanical thrombectomy in acute stroke: effect of collateralization, mismatch, and time to and grade of recanalization on clinical and tissue outcome.
abstract: OBJECTIVE
  Our research focuses on interventional neuroradiology (stroke treatment including imaging methods) and general neuroimaging with an emphasis on functional MR imaging. Our aim was to determine the efficacy of revascularization (TIMI) of middle cerebral and/or carotid artery occlusion by means of mechanical recanalization techniques and to evaluate the impact of collateralization, mismatch in perfusion CT, time to revascularization, grade of revascularization on tissue, and clinical outcome in patients with acute ischemic  stroke.
  
  
  METHODS
  Thirty-one patients with MCA and/or ICA occlusion were included. Ischemic stroke was diagnosed by NECT, CTA, and volume PCT for grading collateralization and mismatch. Time to recanalization was measured from the onset of stroke to the time point of DSA-proved mechanical recanalization. Tissue outcome was calculated by segmentation of infarct size between pre- and postinterventional CT and percentage mismatch lost. Clinical outcome was determined by the  mRS.
  
  
  RESULTS
  Twenty-one of 31 patients (61.8%) presented with MCA and 10/31 patients (38.2%), with distal ICA occlusions. Sufficient recanalization (TIMI 2 and 3) was achieved in 23/31 (75%). Clinical evaluation revealed an mRS score of ≤2 in 25.5%. Age (r = 0.439, P = .038) and TIMI (r = 0.544, P = .002) showed the strongest correlation with clinical outcome. Time to recanalization, TIMI score, and mismatch were associated with a good tissue outcome in  ANOVA.
  
  
  CONCLUSIONS
  Favorable outcome after mechanical recanalization of acute MCA and ICA occlusion depends on time to and grade of recanalization, mismatch, and collateralization. These results indicate that multimodal stroke imaging is helpful to guide therapy decisions and to indicate patients amenable for mechanical  recanalization.
authors.affiliation: Department of Clinical Radiology, University of Münster, Münster, Germany. volker.hesselmann@uni-muenster.de
authors.forename: V
authors.initials: V
authors.lastname: Hesselmann
authors.forename: T
authors.initials: T
authors.lastname: Niederstadt
authors.forename: R
authors.initials: R
authors.lastname: Dziewas
authors.forename: M
authors.initials: M
authors.lastname: Ritter
authors.forename: A
authors.initials: A
authors.lastname: Kemmling
authors.forename: D
authors.initials: D
authors.lastname: Maintz
authors.forename: M
authors.initials: M
authors.lastname: Koehler
authors.forename: H
authors.initials: H
authors.lastname: Seifarth
authors.forename: A H
authors.initials: AH
authors.lastname: Jacobs
authors.forename: E B
authors.initials: EB
authors.lastname: Ringelstein
authors.forename: W
authors.initials: W
authors.lastname: Heindel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000628:therapy*; D002536:Cerebral Arteries; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000628:therapy*; D017131:Thrombectomy / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
references.citation: Eur Radiol. 2005 Nov;15 Suppl 4:D28-31
references.pmid: 16479642
references.citation: Stroke. 2011 Jan;42(1 Suppl):S12-5
references.pmid: 21164129
references.citation: Fortschr Neurol Psychiatr. 1997 Sep;65(9):425-34
references.pmid: 9417427
references.citation: Eur Radiol. 2007 Sep;17(9):2352-8
references.pmid: 17318605
references.citation: AJNR Am J Neuroradiol. 2010 Apr;31(4):628-33
references.pmid: 20019113
references.citation: Eur J Neurol. 2009 Nov;16(11):1210-6
references.pmid: 19659754
references.citation: Stroke. 2007 Apr;38(4):1274-80
references.pmid: 17332445
references.citation: Stroke. 2008 Aug;39(8):2318-24
references.pmid: 18566303
references.citation: Stroke. 2009 May;40(5):1780-5
references.pmid: 19359652
references.citation: Stroke. 2005 Nov;36(11):2400-3
references.pmid: 16224088
references.citation: AJNR Am J Neuroradiol. 2006 Jan;27(1):20-5
references.pmid: 16418350
references.citation: AJNR Am J Neuroradiol. 2008 Aug;29(7):1409-13
references.pmid: 18499798
references.citation: Stroke. 2008 Apr;39(4):e71; author reply e72
references.pmid: 18309159
references.citation: Stroke. 2009 Aug;40(8):2761-8
references.pmid: 19590057
references.citation: Stroke. 2008 Feb;39(2):379-83
references.pmid: 18096842
references.citation: AJNR Am J Neuroradiol. 2009 Mar;30(3):525-31
references.pmid: 19147716
references.citation: Eur Radiol. 2009 Sep;19(9):2286-93
references.pmid: 19350248
references.citation: Stroke. 2009 Mar;40(3):980-2
references.pmid: 19164792
references.citation: Stroke. 2004 Nov;35(11 Suppl 1):2671-4
references.pmid: 15459433
references.citation: Lancet. 1999 Jun 12;353(9169):2036-7
references.pmid: 10376621
references.citation: AJNR Am J Neuroradiol. 2006 Apr;27(4):728-35
references.pmid: 16611754
references.citation: AJNR Am J Neuroradiol. 2007 Feb;28(2):382-4
references.pmid: 17297017
references.citation: AJNR Am J Neuroradiol. 1997 Jun-Jul;18(6):1001-10
references.pmid: 9194425
references.citation: Radiology. 2004 Oct;233(1):79-86
references.pmid: 15340177
references.citation: Clin Neuroradiol. 2010 Dec;20(4):267-8
references.pmid: 21127825