M A Almekhlafi1,2,3, W G Kunz4, R A McTaggart5, M V Jayaraman5, M Najm1, S H Ahn6, E Fainardi7, M Rubiera8, A V Khaw9, A Zini10, M D Hill1,2,3,11, A M Demchuk1,2, M Goyal1,2, B K Menon12,2,3. 1. From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.). 2. Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.). 3. Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.). 4. Department of Radiology (W.G.K.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany. 5. Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island. 6. Department of Neurology (S.H.A.), Chosun University School of Medicine, Gwang Ju, South Korea. 7. Department of Neurosciences and Rehabilitation (E.F.), University Hospital, Ferrara, Italy. 8. Department of Neurology (M.R.), Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, Barcelona, Spain. 9. Department of Clinical Neurosciences (A.V.K.), University of Western Ontario, London, Ontario, Canada. 10. Department of Neurology and Stroke Center (A.Z.), Istituto Di Ricovero e Cura a Carattere Scientifico Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy. 11. Department of Medicine (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada. 12. From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.) docbijoymenon@gmail.com.
Abstract
BACKGROUND AND PURPOSE: The role of collateral imaging in selecting patients for endovascular thrombectomy beyond 6 hours from onset has not been established. To assess the comparative utility of collateral imaging using multiphase CTA in selecting late window patients for EVT. MATERIALS AND METHODS: We used data from a prospective multicenter observational study in which all patients underwent imaging with multiphase CT angiography as well as CTP. Two blinded reviewers evaluated patients' eligibility for endovascular thrombectomy using published collateral imaging (multiphase CTA) criteria compared with CTP using the selection criteria of the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo (DAWN) and Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE-3) trials. CTP images were processed using automated commercial software. The outcomes of patients eligible for endovascular thrombectomy according to multiphase CTA, DAWN, or DEFUSE-3 criteria were compared using multivariable logistic regression modeling. Model characteristics were compared using the C-statistic for the receiver operating characteristic curve, the Akaike information criterion, and the Bayesian information criterion. RESULTS: Eighty-six patients presented beyond 6 hours from onset/last known well (median, 9.6 hours; interquartile range, 4.1 hours). Thirty-five patients (40.7%) received endovascular thrombectomy, of whom good functional outcome (90-day mRS, 0-2) was achieved in 16/35 (47%). Collateral-based imaging paradigms significantly modified the treatment effect of endovascular thrombectomy on 90-day mRS 0-2 (P interaction = .007). The multiphase CTA-based regression model best fit the data for the 90-day outcome (C-statistic, 0.86; 95% CI, 0.77-0.94) and was associated with the least information loss (Akaike information criterion, 95.7; Bayesian information criterion, 114.9) compared with CTP-based models. CONCLUSIONS: The collateral-based imaging paradigm using multiphase CTA compares well with CTP in selecting patients for endovascular thrombectomy in the late time window.
BACKGROUND AND PURPOSE: The role of collateral imaging in selecting patients for endovascular thrombectomy beyond 6 hours from onset has not been established. To assess the comparative utility of collateral imaging using multiphase CTA in selecting late window patients for EVT. MATERIALS AND METHODS: We used data from a prospective multicenter observational study in which all patients underwent imaging with multiphase CT angiography as well as CTP. Two blinded reviewers evaluated patients' eligibility for endovascular thrombectomy using published collateral imaging (multiphase CTA) criteria compared with CTP using the selection criteria of the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo (DAWN) and Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE-3) trials. CTP images were processed using automated commercial software. The outcomes of patients eligible for endovascular thrombectomy according to multiphase CTA, DAWN, or DEFUSE-3 criteria were compared using multivariable logistic regression modeling. Model characteristics were compared using the C-statistic for the receiver operating characteristic curve, the Akaike information criterion, and the Bayesian information criterion. RESULTS: Eighty-six patients presented beyond 6 hours from onset/last known well (median, 9.6 hours; interquartile range, 4.1 hours). Thirty-five patients (40.7%) received endovascular thrombectomy, of whom good functional outcome (90-day mRS, 0-2) was achieved in 16/35 (47%). Collateral-based imaging paradigms significantly modified the treatment effect of endovascular thrombectomy on 90-day mRS 0-2 (P interaction = .007). The multiphase CTA-based regression model best fit the data for the 90-day outcome (C-statistic, 0.86; 95% CI, 0.77-0.94) and was associated with the least information loss (Akaike information criterion, 95.7; Bayesian information criterion, 114.9) compared with CTP-based models. CONCLUSIONS: The collateral-based imaging paradigm using multiphase CTA compares well with CTP in selecting patients for endovascular thrombectomy in the late time window.
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