Endovascular Treatment for Patients With Acute Stroke Who Have a Large Ischemic Core and Large Mismatch Imaging Profile.
OBJECTIVE
Endovascular therapy (ET) is typically not considered for patients with large baseline ischemic cores (irreversibly injured tissue). Computed tomographic perfusion (CTP) imaging may identify a subset of patients with large ischemic cores who remain at risk for significant infarct expansion and thus could still benefit from reperfusion to reduce their degree of disability.


OBJECTIVE
To compare the outcomes of patients with large baseline ischemic cores on CTP undergoing ET with the outcomes of matched controls who had medical care alone.


METHODS
A matched case-control study of patients with proximal occlusion after stroke (intracranial internal carotid artery and/or middle cerebral artery M1 and/or M2) on computed tomographic angiography and baseline ischemic core greater than 50 mL on CTP at a tertiary care center from May 1, 2011, through October 31, 2015. Patients receiving ET and controls receiving medical treatment alone were matched for age, baseline ischemic core volume on CTP, and glucose levels. Baseline characteristics and outcomes were compared.


METHODS
The primary outcome measure was the shift in the degree of disability among the treatment and control groups as measured by the modified Rankin Scale (mRS) (with scores ranging from 0 [fully independent] to 6 [dead]) at 90 days.


RESULTS
Fifty-six patients were matched across 2 equally distributed groups (mean [SD] age, 62.25 [13.92] years for cases and 58.32 [14.79] years for controls; male, 13 cases [46%] and 14 controls [50%]). Endovascular therapy was significantly associated with a favorable shift in the overall distribution of 90-day mRS scores (odds ratio, 2.56; 95% CI, 2.50-8.47; P = .04), higher rates of independent outcomes (90-day mRS scores of 0-2, 25% vs 0%; P = .04), and smaller final infarct volumes (mean [SD], 87 [77] vs 242 [120] mL; P < .001). One control (4%) and 2 treatment patients (7%) developed a parenchymal hematoma type 2 (P > .99). The rates of hemicraniectomy (2 [7%] vs 6 [21%]; P = .10) and 90-day mortality (7 [29%] vs 11 [48%]; P = .75) were numerically lower in the intervention arm. Sensitivity analysis for patients with a baseline ischemic core greater than 70 mL (12 pairs) revealed a significant reduction in final infarct volumes (mean [SD], 110 [65] vs 319 [147] mL; P < .001) but only a nonsignificant improvement in the overall distribution of mRS scores favoring the treatment group (P = .18). All 11 patients older than 75 years had poor outcomes (mRS score >3) at 90 days.


CONCLUSIONS
In properly selected patients, ET appears to benefit patients with large core and large mismatch profiles. Future prospective studies are warranted.
Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Leticia C
LC
Rebello
Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Mehdi
M
Bouslama
Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Diogo C
DC
Haussen
Department of Radiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Seena
S
Dehkharghani
Department of Neurosurgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Jonathan A
JA
Grossberg
Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Samir
S
Belagaje
Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Michael R
MR
Frankel
Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
Raul G
RG
Nogueira
D000328:Adult; D000368:Aged; D020520:Brain Infarction / Q000000981:diagnostic imaging; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000473:pathology*; D016022:Case-Control Studies; D023881:Colonography, Computed Tomographic; D006233:Persons with Disabilities; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000000981:diagnostic imaging* / Q000628:therapy*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome