title: Differential Effect of Baseline Computed Tomographic Angiography Collaterals on Clinical Outcome in Patients Enrolled in the Interventional Management of Stroke III Trial.
abstract: OBJECTIVE
  In the Interventional Management of Stroke (IMS) III trial, we sought to demonstrate evidence of a differential treatment effect of endovascular treatment of acute ischemic stroke compared with intravenous tissue-type plasminogen activator, according to baseline collateral status measured using computed tomographic angiography.
  
  
  METHODS
  Of 656 patients enrolled in Interventional Management of Stroke III trial, 306 had baseline computed tomographic angiography. Of these, 185 patients had M1 middle cerebral artery ± intracranial internal carotid artery occlusion, where baseline collateral status could be measured. Collateral status was assessed by consensus using 3 different ordinal scales and categorized as good, intermediate, and poor. Multivariable modeling was used to assess the effect of collateral status and treatment type on clinical outcome by modified Rankin Scale (mRS 0-2, mRS 0-1, and the ordinal mRS).
  
  
  RESULTS
  Of 185 patients, 126 randomized to endovascular therapy (87.6% recanalized, 41.3% 90-day mRS 0-2) and 59 to intravenous tissue-type plasminogen activator only (60.5% recanalized, 30.5% 90-day mRS 0-2). In multivariable modeling, collateral status was a significant predictor of all clinical outcomes (P<0.05). Maximal benefit with endovascular treatment across all clinical outcomes was seen in patients with intermediate collaterals, some benefit in patients with good collaterals, and none in patients with poor collaterals, although small sample size limited the power of the analysis to show a statistically significant interaction between collateral status and treatment type (P>0.05).
  
  
  CONCLUSIONS
  Using data from a large randomized controlled trial (IMS III), we show that baseline computed tomographic angiography collaterals are a robust determinant of final clinical outcome and could be used to select patients for endovascular therapy.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov/ct2/show/. Unique identifier: 0020NCT00359424.
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Bijoy K
authors: BK
authors: Menon
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Emmad
authors: E
authors: Qazi
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Vivek
authors: V
authors: Nambiar
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Lydia D
authors: LD
authors: Foster
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Sharon D
authors: SD
authors: Yeatts
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: David
authors: D
authors: Liebeskind
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Tudor G
authors: TG
authors: Jovin
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Mayank
authors: M
authors: Goyal
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Michael D
authors: MD
authors: Hill
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Thomas A
authors: TA
authors: Tomsick
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.).
authors: Joseph P
authors: JP
authors: Broderick
authors: From the Calgary Stroke Program and the Department of Clinical Neurosciences (B.K.M., E.Q., V.N., M.G., M.D.H., A.M.D.), Department of Radiology (B.K.M., M.G., M.D.H., A.M.D.), University of Calgary, Calgary, Canada; Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.); Department of Neurosciences, University of California, Los Angeles (D.L.); Department of Neurosciences, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Community Health Sciences, University of Calgary, Calgary, Canada (M.D.H.); Department of Radiology (T.A.T.), Department of Neurology (J.P.B.), University of Cincinnati, OH; and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., M.G., M.D.H., A.M.D.). ademchuk@ucalgary.ca.
authors: Andrew M
authors: AM
authors: Demchuk
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000628:therapy; D002533:Cerebral Angiography; D003097:Collateral Circulation; D057510:Endovascular Procedures; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000000981:diagnostic imaging / Q000628:therapy*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: collateral circulation; endovascular techniques; stroke