Severe carotid stenosis and delay of reperfusion in endovascular stroke treatment: an Interventional Management of Stroke-III study.
OBJECTIVE The impact of extracranial carotid stenosis on interventional revascularization of acute anterior circulation stroke is unknown. The authors examined the effects of high-grade carotid stenosis on the results of endovascular treatment of patients in the Interventional Management of Stroke (IMS)-III trial. METHODS The 278 patients in the endovascular arm of the IMS-III trial were categorized according to the degree of carotid stenosis as determined by angiography. In comparing patients with severe stenosis or occlusion (≥ 70%) to those without severe stenosis (< 70%), the authors evaluated the time to endovascular reperfusion, modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores, 24-hour mean infarct volumes, symptomatic intracerebral hemorrhage rates, and modified Rankin Scale (mRS) scores at 90 days. RESULTS Compared with the 249 patients with less than 70% stenosis, patients with severe stenosis (n = 29) were found to have a significantly longer mean time to reperfusion (105.7 vs 77.7 minutes, p = 0.004); differences in mTICI scores, infarct volumes, hemorrhage rates, and mRS scores at 90 days did not reach statistical significance. Multiple regression analysis revealed that severe carotid stenosis (p < 0.0001) and higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.004) were associated with an increase in time to reperfusion. Older age (p < 0.0001), higher NIHSS score (p < 0.0001), and the absence of reperfusion (p = 0.001) were associated with worse clinical outcomes. CONCLUSIONS Severe ipsilateral ICA stenosis was associated with a significantly longer time to reperfusion in the IMS-III trial. Although these findings may not translate directly to modern devices, this 28-minute delay in reperfusion has significant implications, raising concern over the treatment of tandem ICA stenosis and downstream large-vessel occlusion.
Departments of1Neurosurgery.
Steven L
SL
Gogela
Departments of1Neurosurgery.
Yair M
YM
Gozal
6Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Bin
B
Zhang
3Radiology, University of Cincinnati College of Medicine.
Thomas A
TA
Tomsick
Departments of1Neurosurgery.|4Comprehensive Stroke Center at the University of Cincinnati Neuroscience Institute.|5Mayfield Clinic; and.
Andrew J
AJ
Ringer
2Neurology and Rehabilitation Medicine, and.|4Comprehensive Stroke Center at the University of Cincinnati Neuroscience Institute.
Joseph P
JP
Broderick
2Neurology and Rehabilitation Medicine, and.|4Comprehensive Stroke Center at the University of Cincinnati Neuroscience Institute.
Pooja
P
Khatri
Departments of1Neurosurgery.|4Comprehensive Stroke Center at the University of Cincinnati Neuroscience Institute.|5Mayfield Clinic; and.
Todd A
TA
Abruzzo
D000367:Age Factors; D000368:Aged; D016893:Carotid Stenosis / Q000150:complications* / Q000000981:diagnostic imaging* / Q000628:therapy; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy; D002560:Cerebrovascular Circulation; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
ACA = anterior cerebral artery; AIS = acute ischemic stroke; AOL = arterial occlusive lesion; ASPECTS = Alberta Stroke Program Early CT Scores; ICA = internal carotid artery; IMS = Interventional Management of Stroke; IMS-III; IV = intravenous; MCA = middle cerebral artery; NIHSS = National Institutes of Health Stroke Scale; acute ischemic stroke; carotid stenosis; mRS = modified Rankin Scale; mTICI = modified Thrombolysis in Cerebrovascular Infarction; rTPA = recombinant tissue plasminogen activator; reperfusion; sICH = symptomatic intracerebral hemorrhage; stroke intervention; vascular disorders