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Lansberg MG, Straka M, Kemp S, Mlynash M, Wechsler LR, Jovin TG, Wilder MJ, Lutsep HL, Czartoski TJ, Bernstein RA, Chang CW, Warach S, Fazekas F, Inoue M, Tipirneni A, Hamilton SA, Zaharchuk G, Marks MP, Bammer R, Albers GW. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol 2012; 11:860-7. [PMID: 22954705 PMCID: PMC4074206 DOI: 10.1016/s1474-4422(12)70203-x] [Citation(s) in RCA: 595] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Whether endovascular stroke treatment improves clinical outcomes is unclear because of the paucity of data from randomised placebo-controlled trials. We aimed to establish whether MRI can be used to identify patients who are most likely to benefit from endovascular reperfusion. METHODS In this prospective cohort study we consecutively enrolled patients scheduled to have endovascular treatment within 12 h of onset of stroke at eight centres in the USA and one in Austria. Aided by an automated image analysis computer program, investigators interpreted a baseline MRI scan taken before treatment to establish whether the patient had an MRI profile (target mismatch) that suggested salvageable tissue was present. Reperfusion was assessed on an early follow-up MRI scan (within 12 h of the revascularisation procedure) and defined as a more than 50% reduction in the volume of the lesion from baseline on perfusion-weighted MRI. The primary outcome was favourable clinical response, defined as an improvement of 8 or more on the National Institutes of Health Stroke Scale between baseline and day 30 or a score of 0-1 at day 30. The secondary clinical endpoint was good functional outcome, defined as a modified Rankin scale score of 2 or less at day 90. Analyses were adjusted for imbalances in baseline predictors of outcome. Investigators assessing outcomes were masked to baseline data. FINDINGS 138 patients were enrolled. 110 patients had catheter angiography and of these 104 had an MRI profile and 99 could be assessed for reperfusion. 46 of 78 (59%) patients with target mismatch and 12 of 21 (57%) patients without target mismatch had reperfusion after endovascular treatment. The adjusted odds ratio (OR) for favourable clinical response associated with reperfusion was 8·8 (95% CI 2·7-29·0) in the target mismatch group and 0·2 (0·0-1·6) in the no target mismatch group (p=0·003 for difference between ORs). Reperfusion was associated with increased good functional outcome at 90 days (OR 4·0, 95% CI 1·3-12·2) in the target mismatch group, but not in the no target mismatch group (1·9, 0·2-18·7). INTERPRETATION Target mismatch patients who had early reperfusion after endovascular stroke treatment had more favourable clinical outcomes. No association between reperfusion and favourable outcomes was present in patients without target mismatch. Our data suggest that a randomised controlled trial of endovascular treatment for patients with the target mismatch profile is warranted. FUNDING National Institute for Neurological Disorders and Stroke.
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Affiliation(s)
- Maarten G. Lansberg
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Matus Straka
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Stephanie Kemp
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Michael Mlynash
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | | | - Tudor G. Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Michael J. Wilder
- Division of Vascular Neurology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Helmi L. Lutsep
- Oregon Stroke Center, Oregon Health & Science University, Portland, OR
| | | | - Richard A. Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Cherylee W.J. Chang
- The Queen’s Medical Center, University of Hawaii John A. Burns School of Medicine, Honolulu, HI
| | - Steven Warach
- Section on Stroke Diagnostics and Therapeutics, Division of Intramural Research, NINDS, Bethesda, MD
| | - Franz Fazekas
- Department of Neurology, Graz University School of Medicine, Graz, Austria
| | - Manabu Inoue
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Aaryani Tipirneni
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Scott A. Hamilton
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Greg Zaharchuk
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Michael P. Marks
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Roland Bammer
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Gregory W. Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
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Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Sobesky J. Influence of the Arterial Input Function on Absolute and Relative Perfusion-Weighted Imaging Penumbral Flow Detection. Stroke 2012; 43:378-85. [DOI: 10.1161/strokeaha.111.635458] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Perfusion-weighted imaging maps are used to identify critical hypoperfusion in acute stroke. However, quantification of perfusion may depend on the choice of the arterial input function (AIF). Using quantitative positron emission tomography we evaluated the influence of the AIF location on maps of absolute and relative perfusion-weighted imaging to detect penumbral flow (PF; <20 mL/100 g/min on positron emission tomography
CBF
) in acute stroke.
Methods—
In 22 patients with acute stroke the AIF was placed at 7 sites (M1, M2, M3 ipsi- and contralateral and internal carotid artery–M1 contralateral to the infarct). Comparative
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O-water positron emission tomography and AIF-dependent perfusion-weighted imaging (cerebral blood flow, cerebral blood volume, mean transit time, and time to maximum) were performed. A receiver operating characteristic curve analysis described the threshold independent performance (area under the curve) of the perfusion-weighted maps for all 7 AIF locations and identified the best AIF-dependent absolute and relative thresholds to identify PF. These results were compared with AIF-independent time-to-peak maps.
Results—
Quantitative perfusion-weighted imaging maps of cerebral blood flow and time to maximum performed best. For PF detection, AIF placement did significantly influence absolute PF thresholds. However, AIF placement did not influence (1) the threshold independent performance; and (2) the relative PF thresholds. AIF placement in the proximal segment of the contralateral middle cerebral artery (cM1) was preferable for quantification.
Conclusions—
AIF-based maps of cerebral blood flow and time to maximum were most accurate to detect the PF threshold. The AIF placement significantly altered absolute PF thresholds and showed best agreement with positron emission tomography for the cM1 segment. The performance of relative PF thresholds, however, was not AIF location-dependent and might be along with AIF-independent time-to-peak maps, more suitable than absolute PF thresholds in acute stroke if detailed postprocessing is not feasible.
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Affiliation(s)
- Olivier Zaro-Weber
- From the Max Planck Institute for Neurological Research (O.Z.-W., W.-D.H.), Cologne, Germany; the Departments of Neurology (O.Z.-W.) and Diagnostic Radiology (W.M.-H.), University of Cologne, Cologne, Germany; and the Department of Neurology and Center for Stroke Research Berlin (O.Z.-W., J.S.), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Walter Moeller-Hartmann
- From the Max Planck Institute for Neurological Research (O.Z.-W., W.-D.H.), Cologne, Germany; the Departments of Neurology (O.Z.-W.) and Diagnostic Radiology (W.M.-H.), University of Cologne, Cologne, Germany; and the Department of Neurology and Center for Stroke Research Berlin (O.Z.-W., J.S.), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wolf-Dieter Heiss
- From the Max Planck Institute for Neurological Research (O.Z.-W., W.-D.H.), Cologne, Germany; the Departments of Neurology (O.Z.-W.) and Diagnostic Radiology (W.M.-H.), University of Cologne, Cologne, Germany; and the Department of Neurology and Center for Stroke Research Berlin (O.Z.-W., J.S.), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Sobesky
- From the Max Planck Institute for Neurological Research (O.Z.-W., W.-D.H.), Cologne, Germany; the Departments of Neurology (O.Z.-W.) and Diagnostic Radiology (W.M.-H.), University of Cologne, Cologne, Germany; and the Department of Neurology and Center for Stroke Research Berlin (O.Z.-W., J.S.), Charité-Universitätsmedizin Berlin, Berlin, Germany
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