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Menjot de Champfleur N, Saver JL, Goyal M, Jahan R, Diener HC, Bonafe A, Levy EI, Pereira VM, Cognard C, Yavagal DR, Albers GW. Efficacy of Stent-Retriever Thrombectomy in Magnetic Resonance Imaging Versus Computed Tomographic Perfusion-Selected Patients in SWIFT PRIME Trial (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke). Stroke 2017; 48:1560-1566. [PMID: 28465460 DOI: 10.1161/strokeaha.117.016669] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/06/2017] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The majority of patients enrolled in SWIFT PRIME trial (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke) had computed tomographic perfusion (CTP) imaging before randomization; 34 patients were randomized after magnetic resonance imaging (MRI). METHODS Patients with middle cerebral artery and distal carotid occlusions were randomized to treatment with tPA (tissue-type plasminogen activator) alone or tPA+stentriever thrombectomy. The primary outcome was the distribution of the modified Rankin Scale score at 90 days. Patients with the target mismatch profile for enrollment were identified on MRI and CTP. RESULTS MRI selection was performed in 34 patients; CTP in 139 patients. Baseline National Institutes of Health Stroke Scale score was 17 in both groups. Target mismatch profile was present in 95% (MRI) versus 83% (CTP). A higher percentage of the MRI group was transferred from an outside hospital (P=0.02), and therefore, the time from stroke onset to randomization was longer in the MRI group (P=0.003). Time from emergency room arrival to randomization did not differ in CTP versus MRI-selected patients. Baseline ischemic core volumes were similar in both groups. Reperfusion rates (>90%/TICI [Thrombolysis in Cerebral Infarction] score 3) did not differ in the stentriever-treated patients in the MRI versus CTP groups. The primary efficacy analysis (90-day mRS score) demonstrated a statistically significant benefit in both subgroups (MRI, P=0.02; CTP, P=0.01). Infarct growth was reduced in the stentriever-treated group in both MRI and CTP groups. CONCLUSIONS Time to randomization was significantly longer in MRI-selected patients; however, site arrival to randomization times were not prolonged, and the benefits of endovascular therapy were similar. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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Affiliation(s)
- Nicolas Menjot de Champfleur
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.).
| | - Jeffrey L Saver
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Mayank Goyal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Reza Jahan
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Hans-Christoph Diener
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Alain Bonafe
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Elad I Levy
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Vitor M Pereira
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Christophe Cognard
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Dileep R Yavagal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Gregory W Albers
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
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Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, Pereira VM, Cognard C, Yavagal DR, Saver JL. Relationships Between Imaging Assessments and Outcomes in Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke. Stroke 2015; 46:2786-94. [PMID: 26316344 DOI: 10.1161/strokeaha.115.010710] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Imaging findings can predict outcomes in patients with acute stroke. Relationships between imaging findings and clinical and imaging outcomes in patients randomized to intravenous tissue-type plasminogen activator-alone versus tissue-type plasminogen activator plus endovascular therapy (Solitaire device) in the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) study were assessed. METHODS We evaluated associations between imaging assessments (baseline mismatch profiles/ischemic core volumes and successful reperfusion) with imaging outcomes (27-hour infarct volume/growth) and clinical outcomes (modified Rankin Scale scores at 90 days). Imaging variables that predict favorable clinical outcomes were assessed in both univariate and multivariate models. RESULTS One hundred and ninety-five patients were included. Successful reperfusion and infarct volume (assessed at 27 hours) were powerful independent predictors of favorable clinical outcomes (modified Rankin Scale score of 0-2 at 90 days). Patients with the target mismatch profile at baseline had a higher rate of reperfusion, lesser infarct growth, smaller infarct volumes, and better clinical outcomes in the Solitaire plus tissue-type plasminogen activator (intervention) group than those in the tissue-type plasminogen activator-alone (control) group. Patients with larger mismatch volumes at baseline had a trend toward better treatment response in the intervention group than patients who had smaller (<50 mL) mismatch volumes. CONCLUSIONS Patients who achieved reperfusion had substantially more favorable clinical and imaging outcomes in both the intervention and the control groups. Infarct volume at 27 hours strongly correlated with clinical outcome at 90 days in both treatment groups. SWIFT PRIME patients with the target mismatch profile had a highly favorable response to endovascular therapy on both clinical and imaging outcomes. Both reperfusion and infarct volumes at 27 hours were powerful and independent predictors of 90-day clinical outcomes. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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Affiliation(s)
- Gregory W Albers
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.).
| | - Mayank Goyal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Reza Jahan
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Alain Bonafe
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Hans-Christoph Diener
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Elad I Levy
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Vitor M Pereira
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Christophe Cognard
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Dileep R Yavagal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Jeffrey L Saver
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
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Zhu G, Michel P, Jovin T, Patrie JT, Xin W, Eskandari A, Zhang W, Wintermark M. Prediction of recanalization in acute stroke patients receiving intravenous and endovascular revascularization therapy. Int J Stroke 2014; 10:28-36. [PMID: 24975168 DOI: 10.1111/ijs.12312] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 04/29/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The study aims to assess the recanalization rate in acute ischemic stroke patients who received no revascularization therapy, intravenous thrombolysis, and endovascular treatment, respectively, and to identify best clinical and imaging predictors of recanalization in each treatment group. METHODS Clinical and imaging data were collected in 103 patients with acute ischemic stroke caused by anterior circulation arterial occlusion. We recorded demographics and vascular risk factors. We reviewed the noncontrast head computed tomographies to assess for hyperdense middle cerebral artery and its computed tomography density. We reviewed the computed tomography angiograms and the raw images to determine the site and degree of arterial occlusion, collateral score, clot burden score, and the density of the clot. Recanalization status was assessed on recanalization imaging using Thrombolysis in Myocardial Ischemia. Multivariate logistic regressions were utilized to determine the best predictors of outcome in each treatment group. RESULTS Among the 103 study patients, 43 (42%) received intravenous thrombolysis, 34 (33%) received endovascular thrombolysis, and 26 (25%) did not receive any revascularization therapy. In the patients with intravenous thrombolysis or no revascularization therapy, recanalization of the vessel was more likely with intravenous thrombolysis (P = 0·046) and when M1/A1 was occluded (P = 0·001). In this subgroup of patients, clot burden score, cervical degree of stenosis (North American Symptomatic Carotid Endarterectomy Trial), and hyperlipidemia status added information to the aforementioned likelihood of recanalization at the patient level (P < 0·001). In patients with endovascular thrombolysis, recanalization of the vessel was more likely in the case of a higher computed tomography angiogram clot density (P = 0·012), and in this subgroup of patients gender added information to the likelihood of recanalization at the patient level (P = 0·044). CONCLUSION The overall likelihood of recanalization was the highest in the endovascular group, and higher for intravenous thrombolysis compared with no revascularization therapy. However, our statistical models of recanalization for each individual patient indicate significant variability between treatment options, suggesting the need to include this prediction in the personalized treatment selection.
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Affiliation(s)
- Guangming Zhu
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China; Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA, USA
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Puig J, Pedraza S, Demchuk A, Daunis-I-Estadella J, Termes H, Blasco G, Soria G, Boada I, Remollo S, Baños J, Serena J, Castellanos M. Quantification of thrombus hounsfield units on noncontrast CT predicts stroke subtype and early recanalization after intravenous recombinant tissue plasminogen activator. AJNR Am J Neuroradiol 2011; 33:90-6. [PMID: 22158924 DOI: 10.3174/ajnr.a2878] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about the factors that determine recanalization after intravenous thrombolysis. We assessed the value of thrombus Hounsfield unit quantification as a predictive marker of stroke subtype and MCA recanalization after intravenous rtPA treatment. MATERIALS AND METHODS NCCT scans and CTA were performed on patients with MCA acute stroke within 4.5 hours of symptom onset. Demographics, stroke severity, vessel hyperattenuation, occlusion site, thrombus length, and time to thrombolysis were recorded. Stroke origin was categorized as LAA, cardioembolic, or indeterminate according to TOAST criteria. Two blinded neuroradiologists calculated the Hounsfield unit values for the thrombus and contralateral MCA segment. We used ROC curves to determine the rHU cutoff point to discriminate patients with successful recanalization from those without. We assessed the accuracy (sensitivity, specificity, and positive and negative predictive values) of rHU in the prediction of recanalization. RESULTS Of 87 consecutive patients, 45 received intravenous rtPA and only 15 (33.3%) patients had acute recanalization. rHU values and stroke mechanism were the highest predictive factors of recanalization. The Matthews correlation coefficient was highest for rHU (0.901). The sensitivity, specificity, and positive and negative predictive values for lack of recanalization after intravenous rtPA for rHU ≤ 1.382 were 100%, 86.67%, 93.75%, and 100%, respectively. LAA thrombi had lower rHU than cardioembolic and indeterminate stroke thrombi (P = .004). CONCLUSIONS The Hounsfield unit thrombus measurement ratio can predict recanalization with intravenous rtPA and may have clinical utility for endovascular treatment decision making.
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Affiliation(s)
- J Puig
- Department of Radiology, Girona Biomedical Research Institute, Hospital Universitari de Girona Dr Josep Trueta, Spain.
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