Pierre Seners1,2, Catherine Oppenheim3, Guillaume Turc1, Jean-François Albucher4, Adrien Guenego5, Nicolas Raposo4, Soren Christensen6, Lionel Calvière4, Alain Viguier4, Jean Darcourt5, Anne-Christine Januel5, Michael Mlynash6, Agnes Sommet7, Claire Thalamas7, Igor Sibon8, Vanessa Rousseau7, Thomas Tourdias9, Patrice Menegon9, Fabrice Bonneville5, Mikael Mazighi10, Sylvain Charron3, Laurence Legrand3, Christophe Cognard5, Gregory W Albers6, Jean-Claude Baron1, Jean-Marc Olivot4. 1. Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France. 2. Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France. 3. Radiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France. 4. Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France. 5. Department of Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France. 6. Stanford Stroke Center, Stanford University, Palo Alto, CA. 7. Clinical Investigation Center, Centre Hospitalier Universitaire de Toulouse, Toulouse, France. 8. Unité Neurovasculaire, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France. 9. Department of Neuroradiology, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France. 10. Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France.
Abstract
OBJECTIVE: Mechanical thrombectomy (MT) is not recommended for acute stroke with large vessel occlusion (LVO) and a large volume of irreversibly injured tissue ("core"). Perfusion imaging may identify a subset of patients with large core who benefit from MT. METHODS: We compared two cohorts of LVO-related patients with large core (>50 ml on diffusion-weighted-imaging or CT-perfusion using RAPID), available perfusion imaging, and treated within 6 hours from onset by either MT + Best Medical Management (BMM) in one prospective study, or BMM alone in the pre-MT era from a prospective registry. Primary outcome was 90-day modified Rankin Scale ≤2. We searched for an interaction between treatment group and amount of penumbra as estimated by the mismatch ratio (MMRatio = critical hypoperfusion/core volume). RESULTS: Overall, 107 patients were included (56 MT + BMM and 51 BMM): Mean age was 68 ± 15 years, median core volume 99 ml (IQR: 72-131) and MMRatio 1.4 (IQR: 1.0-1.9). Baseline clinical and radiological variables were similar between the two groups, except for a higher intravenous thrombolysis rate in the BMM group. The MMRatio strongly modified the clinical outcome following MT (pinteraction < 0.001 for continuous MMRatio); MT was associated with a higher rate of good outcome in patients with, but not in those without, MMRatio>1.2 (adjusted OR [95% CI] = 6.8 [1.7-27.0] vs 0.7 [0.1-6.2], respectively). Similar findings were present for MMRatio ≥1.8 in the subgroup with core ≥70 ml. Parenchymal hemorrhage on follow-up imaging was more frequent in the MT + BMM group regardless of the MMRatio. INTERPRETATION: Perfusion imaging may help select which patients with large core should be considered for MT. Randomized studies are warranted. ANN NEUROL 2021.
OBJECTIVE: Mechanical thrombectomy (MT) is not recommended for acute stroke with large vessel occlusion (LVO) and a large volume of irreversibly injured tissue ("core"). Perfusion imaging may identify a subset of patients with large core who benefit from MT. METHODS: We compared two cohorts of LVO-related patients with large core (>50 ml on diffusion-weighted-imaging or CT-perfusion using RAPID), available perfusion imaging, and treated within 6 hours from onset by either MT + Best Medical Management (BMM) in one prospective study, or BMM alone in the pre-MT era from a prospective registry. Primary outcome was 90-day modified Rankin Scale ≤2. We searched for an interaction between treatment group and amount of penumbra as estimated by the mismatch ratio (MMRatio = critical hypoperfusion/core volume). RESULTS: Overall, 107 patients were included (56 MT + BMM and 51 BMM): Mean age was 68 ± 15 years, median core volume 99 ml (IQR: 72-131) and MMRatio 1.4 (IQR: 1.0-1.9). Baseline clinical and radiological variables were similar between the two groups, except for a higher intravenous thrombolysis rate in the BMM group. The MMRatio strongly modified the clinical outcome following MT (pinteraction < 0.001 for continuous MMRatio); MT was associated with a higher rate of good outcome in patients with, but not in those without, MMRatio>1.2 (adjusted OR [95% CI] = 6.8 [1.7-27.0] vs 0.7 [0.1-6.2], respectively). Similar findings were present for MMRatio ≥1.8 in the subgroup with core ≥70 ml. Parenchymal hemorrhage on follow-up imaging was more frequent in the MT + BMM group regardless of the MMRatio. INTERPRETATION: Perfusion imaging may help select which patients with large core should be considered for MT. Randomized studies are warranted. ANN NEUROL 2021.
Authors: Noemie Ligot; Sophie Elands; Charlotte Damien; Lise Jodaitis; Niloufar Sadeghi Meibodi; Benjamin Mine; Thomas Bonnet; Adrien Guenego; Boris Lubicz; Gilles Naeije Journal: Front Neurol Date: 2022-02-21 Impact factor: 4.003