Endovascular treatment benefits some acute stroke patients with large ischemic core
medwireNews: Irreversibly damaged tissue should not rule out endovascular treatment for acute ischemic stroke for all patients, case–control study findings in JAMA Neurology suggest.
The study researchers found the treatment beneficial in 28 patients who had a baseline ischemic core greater than 50 mL on computed tomographic perfusion (CTP) and large mismatch profiles.
The target mismatch profile on CTP was ischemic cores (regional cerebral blood flow reduction below 30%) of 50 to 150 mL with a greater than 40 mL difference between volumes of critically hypoperfused tissue (time to maximum tissue residue function of more than 6 second) involving eloquent areas and ischemic core.
In an editorial relating to the study, David Liebeskind (University of California, Los Angeles, USA) points out: “This seeming complex imaging definition potentially avoids futile reperfusion and recognizes eloquence of disparate brain volumes.”
Patients receiving endovascular treatment had a 2.56 times improved odds of having a more favorable 90-day distribution of modified Rankin Scale (mRS) relative to 28 patients matched for age, baseline ischemic core on CTP, and pretreatment glucose levels.
And 25% of patients receiving endovascular treatment had scores of 0–2, indicating no to slight disability, compared with 0% of those not receiving treatment.
Final infarct volumes were smaller following treatment, at an average of 87 versus 242 mL, and the rates of hemicraniectomy and 90-day mortality were numerically lower, at 7% versus 21% and 29% versus 48%, respectively.
Parenchymal hematoma type 2 occurred in only two of the patients receiving treatment and one of those who did not.
The findings were similar when 12 matched pairs with baseline ischemic cores greater than 70 mL were considered separately. Final infarct volumes were significantly reduced and the overall distribution of mRS scores among treated patients improved, albeit not significantly.
Age was a limiting factor, however, with poor outcomes seen for all patients older than 75 years of age – six in the intervention group and five in the control group – with mRS scores greater than 3.
Raul Nogueira (Emory University School of Medicine, Atlanta, Georgia, USA) and fellow researchers comment that it would not be reasonable to expect all patients with a large baseline infarct to achieve independence, so “our goal should be a better outcome compared with what we would have had without [endovascular therapy].”
They add: “There is no logical sense in withholding endovascular reperfusion in a patient with a baseline ischemic core of 80 mL in the setting of a significantly larger mismatch only to perform a hemicraniectomy moments later when one could have potentially performed reperfusion, saved brain tissue, and avoided a more invasive and expensive surgical procedure.”
Liebeskind says the study provides a “great example of theranostics in stroke imaging.”
He continues: “This example of theranostics in stroke imaging indicates how diagnostics and therapeutics may be intertwined to optimize care of an individual rather than simply comparing such individual pathophysiologic findings with the remainder of the population.”
medwireNews is an independent medical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2016