Collaterals at angiography and outcomes in the Interventional Management of Stroke (IMS) III trial.
OBJECTIVE
Endovascular strategies provide unique opportunity to correlate angiographic measures of collateral circulation at the time of endovascular therapy. We conducted systematic analyses of collaterals at conventional angiography on recanalization, reperfusion, and clinical outcomes in the endovascular treatment arm of the Interventional Management of Stroke (IMS) III trial.


METHODS
Prospective evaluation of angiographic collaterals was conducted via central review of subjects treated with endovascular therapy in IMS III (n=331). Collateral grade before endovascular therapy was assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, blinded to all other data. Statistical analyses investigated the association between collaterals with baseline clinical variables, angiographic measures of recanalization, reperfusion and clinical outcomes.


RESULTS
Adequate views of collateral circulation to the ischemic territory were available in 276 of 331 (83%) subjects. Collateral grade was strongly related to both recanalization of the occluded arterial segment (P=0.0016) and downstream reperfusion (P<0.0001). Multivariable analyses confirmed that robust angiographic collateral grade was a significant predictor of good clinical outcome (modified Rankin Scale score≤2) at 90 days (P=0.0353), adjusted for age, history of diabetes mellitus, National Institutes of Health Stroke Scale strata, and Alberta Stroke Program Early CT Score. The relationship between collateral flow and clinical outcome may depend on the degree of reperfusion.


CONCLUSIONS
More robust collateral grade was associated with better recanalization, reperfusion, and subsequent better clinical outcomes. These data, from the largest endovascular trial to date, suggest that collaterals are an important consideration in future trial design.


BACKGROUND
http://www.clinicaltrials.gov. Unique identifier: NCT00359424.
From UCLA Stroke Center, Los Angeles, CA (D.S.L.); University of Cincinnati, Cincinnati, OH (T.A.T., J.C., P.K., J.P.B.); Medical University of South Carolina, Charleston, SC (L.D.F., S.D.Y., Y.Y.P.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.G., B.K.M.); UPMC Stroke Institute, Pittsburgh, PA (T.G.J.); Department of Neuroradiology, University of Dresden, Dresden, Germany (R.v.K.); University of Mississippi, Jackson, MS (R.M.S.); Medical College of Wisconsin/Froedtert Hospital, Milwaukee, WI (O.O.Z.); Michigan State University, East Lansing, MI (S.I.H.); Summit Neurovascular Specialties and Akron General Hospital, Akron, OH (F.A.A.); and Royal Melbourne Hospital, Parkville, Victoria, Australia (B.Y.).
David S
DS
Liebeskind
Thomas A
TA
Tomsick
Lydia D
LD
Foster
Sharon D
SD
Yeatts
Janice
J
Carrozzella
Andrew M
AM
Demchuk
Tudor G
TG
Jovin
Pooja
P
Khatri
Ruediger
R
von Kummer
Rebecca M
RM
Sugg
Osama O
OO
Zaidat
Syed I
SI
Hussain
Mayank
M
Goyal
Bijoy K
BK
Menon
Firas
F
Al Ali
Bernard
B
Yan
Yuko Y
YY
Palesch
Joseph P
JP
Broderick
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure / Q000502:physiology; D002533:Cerebral Angiography / Q000379:methods*; D003097:Collateral Circulation / Q000502:physiology*; D015897:Comorbidity; D048909:Diabetes Complications / Q000453:epidemiology / Q000628:therapy; D057510:Endovascular Procedures; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D015427:Reperfusion Injury / Q000517:prevention & control; D020521:Stroke / Q000175:diagnosis* / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D055815:Young Adult
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
angiography; collateral circulation; reperfusion; stroke