Justus F Kleine1, Mirjam Kaesmacher2, Benedikt Wiestler2, Johannes Kaesmacher2. 1. From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, Technical University Munich, Germany (J.F.K., M.K., B.W., J.K.); and Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Germany (J.F.K.). justus.kleine@charite.de. 2. From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, Technical University Munich, Germany (J.F.K., M.K., B.W., J.K.); and Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Germany (J.F.K.).
Abstract
BACKGROUND AND PURPOSE: White matter (WM) is less vulnerable to ischemia than gray matter. In ischemic stroke caused by acute large-vessel occlusion, successful recanalization might therefore sometimes selectively salvage the WM, leading to infarct patterns confined to gray matter. This study examines occurrence, determinants, and clinical significance of such effects. METHODS: Three hundred twenty-two patients with acute middle cerebral artery occlusion subjected to mechanical thrombectomy were included. Infarct patterns were categorized into WM- (sparing the WM) and WM+ (involving WM). National Institutes of Health Stroke Scale-based measures of neurological outcome, including National Institutes of Health Stroke Scale improvement or National Institutes of Health Stroke Scale worsening, good functional midterm outcome (day 90-modified Rankin Scale score of ≤2), the occurrence of malignant swelling, and in-hospital mortality were predefined outcome measures. RESULTS: WM- infarcts occurred in 118 of 322 patients and were associated with successful recanalization and better collateral grades (P<0.05). Shorter symptom-onset to recanalization times were also associated with WM- infarcts in univariate analysis, but not when adjusted for collateral grades. WM- infarcts were independently associated with good neurological outcome (adjusted odds ratio, 3.003; 95% confidence interval, 1.186-7.607; P=0.020) and good functional midterm outcome (adjusted odds ratio, 8.618; 95% confidence interval, 2.409-30.828; P=0.001) after correcting for potential confounders, including final infarct volume. Only 2.6% of WM- patients, but 20.5% of WM+ patients exhibited neurological worsening, and none versus 12.8% developed malignant swelling (P<0.001), contributing to lower mortality in this group (2.5% versus 10.3%; P=0.014). CONCLUSIONS: WM infarction commonly commences later than gray matter infarction after acute middle cerebral artery occlusion. Successful recanalization can therefore salvage completely the WM at risk in many patients even several hours after symptom onset. Preservation of the WM is associated with better neurological recovery, prevention of malignant swelling, and reduced mortality. This has important implications for neuroprotective strategies, and perfusion imaging-based patient selection, and provides a rationale for treating selected patients in extended time windows.
BACKGROUND AND PURPOSE:White matter (WM) is less vulnerable to ischemia than gray matter. In ischemic stroke caused by acute large-vessel occlusion, successful recanalization might therefore sometimes selectively salvage the WM, leading to infarct patterns confined to gray matter. This study examines occurrence, determinants, and clinical significance of such effects. METHODS: Three hundred twenty-two patients with acute middle cerebral artery occlusion subjected to mechanical thrombectomy were included. Infarct patterns were categorized into WM- (sparing the WM) and WM+ (involving WM). National Institutes of Health Stroke Scale-based measures of neurological outcome, including National Institutes of Health Stroke Scale improvement or National Institutes of Health Stroke Scale worsening, good functional midterm outcome (day 90-modified Rankin Scale score of ≤2), the occurrence of malignant swelling, and in-hospital mortality were predefined outcome measures. RESULTS: WM- infarcts occurred in 118 of 322 patients and were associated with successful recanalization and better collateral grades (P<0.05). Shorter symptom-onset to recanalization times were also associated with WM- infarcts in univariate analysis, but not when adjusted for collateral grades. WM- infarcts were independently associated with good neurological outcome (adjusted odds ratio, 3.003; 95% confidence interval, 1.186-7.607; P=0.020) and good functional midterm outcome (adjusted odds ratio, 8.618; 95% confidence interval, 2.409-30.828; P=0.001) after correcting for potential confounders, including final infarct volume. Only 2.6% of WM- patients, but 20.5% of WM+ patients exhibited neurological worsening, and none versus 12.8% developed malignant swelling (P<0.001), contributing to lower mortality in this group (2.5% versus 10.3%; P=0.014). CONCLUSIONS: WM infarction commonly commences later than gray matter infarction after acute middle cerebral artery occlusion. Successful recanalization can therefore salvage completely the WM at risk in many patients even several hours after symptom onset. Preservation of the WM is associated with better neurological recovery, prevention of malignant swelling, and reduced mortality. This has important implications for neuroprotective strategies, and perfusion imaging-based patient selection, and provides a rationale for treating selected patients in extended time windows.
Authors: Sarah Christina Reitz; Ellen Gerhard; Stella Breuer; Ferdinand Oliver Bohmann; Waltraud Pfeilschifter; Joachim Berkefeld Journal: J Clin Med Date: 2022-05-17 Impact factor: 4.964
Authors: Johannes Kaesmacher; Mirjam Kaesmacher; Maria Berndt; Christian Maegerlein; Sebastian Mönch; Silke Wunderlich; Thomas R Meinel; Urs Fischer; Claus Zimmer; Tobias Boeckh-Behrens; Justus F Kleine Journal: Stroke Date: 2021-04-08 Impact factor: 7.914
Authors: Robert W Regenhardt; Mark R Etherton; Alvin S Das; Markus D Schirmer; Joshua A Hirsch; Christopher J Stapleton; Aman B Patel; Thabele M Leslie-Mazwi; Natalia S Rost Journal: J Stroke Cerebrovasc Dis Date: 2020-12-29 Impact factor: 2.136
Authors: J M Ospel; M D Hill; B K Menon; A Demchuk; R McTaggart; R Nogueira; A Poppe; D Haussen; W Qiu; A Mayank; M Almekhlafi; C Zerna; M Joshi; M Jayaraman; D Roy; J Rempel; B Buck; M Tymianski; M Goyal Journal: AJNR Am J Neuroradiol Date: 2021-06-24 Impact factor: 4.966