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Demchuk AM, Goyal M, Yeatts SD, Carrozzella J, Foster LD, Qazi E, Hill MD, Jovin TG, Ribo M, Yan B, Zaidat OO, Frei D, von Kummer R, Cockroft KM, Khatri P, Liebeskind DS, Tomsick TA, Palesch YY, Broderick JP. Recanalization and clinical outcome of occlusion sites at baseline CT angiography in the Interventional Management of Stroke III trial. Radiology 2014; 273:202-10. [PMID: 24895878 DOI: 10.1148/radiol.14132649] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To use baseline computed tomographic (CT) angiography to analyze imaging and clinical end points in an Interventional Management of Stroke III cohort to identify patients who would benefit from endovascular stroke therapy. MATERIALS AND METHODS The primary clinical end point was 90-day dichotomized modified Rankin Scale (mRS) score. Secondary end points were 90-day mRS score distribution and 24-hour recanalization. Prespecified subgroup was baseline proximal occlusions (internal carotid, M1, or basilar arteries). Exploratory analyses were subsets with any occlusion and specific sites of occlusion (two-sided α = .01). RESULTS Of 656 subjects, 306 (47%) underwent baseline CT angiography or magnetic resonance angiography. Of 306, 282 (92%) had arterial occlusions. At baseline CT angiography, proximal occlusions (n = 220) demonstrated no difference in primary outcome (41.3% [62 of 150] endovascular vs 38% [27 of 70] intravenous [IV] tissue-plasminogen activator [tPA]; relative risk, 1.07 [99% confidence interval: 0.67, 1.70]; P = .70); however, 24-hour recanalization rate was higher for endovascular treatment (n = 167; 84.3% [97 of 115] endovascular vs 56% [29 of 52] IV tPA; P < .001). Exploratory subgroup analysis for any occlusion at baseline CT angiography did not demonstrate significant differences between endovascular and IV tPA arms for primary outcome (44.7% [85 of 190] vs 38% [35 of 92], P = .29), although ordinal shift analysis of full mRS distribution demonstrated a trend toward more favorable outcome (P = .011). Carotid T- or L-type occlusion (terminal internal carotid artery [ICA] with M1 middle cerebral artery and/or A1 anterior cerebral artery involvement) or tandem (extracranial or intracranial) ICA and M1 occlusion subgroup also showed a trend favoring endovascular treatment over IV tPA alone for primary outcome (26% [12 of 46] vs 4% [one of 23], P = .047). CONCLUSION Significant differences were identified between treatment arms for 24-hour recanalization in proximal occlusions; carotid T- or L-type and tandem ICA and M1 occlusions showed greater recanalization and a trend toward better outcome with endovascular treatment. Vascular imaging should be mandated in future endovascular trials to identify such occlusions. Online supplemental material is available for this article.
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Affiliation(s)
- Andrew M Demchuk
- From the Calgary Stroke Program, Dept of Clinical Neurosciences and Radiology, Hotchkiss Brain Inst, Univ of Calgary, 1403 29 St NW, Room 112, Calgary, AB, Canada T2N 2T9 (A.M.D., M.G., E.Q., M.D.H.); Dept of Public Health Sciences, Medical Univ of South Carolina, Charleston, SC (S.D.Y., L.D.F., Y.Y.P.); Depts of Neurology and Rehabilitation Medicine and Radiology, Univ of Cincinnati Academic Health Ctr, Cincinnati, Ohio (J.C., P.K., T.A.T., J.P.B.); Stroke Inst, Univ of Pittsburgh Medical Ctr, Pittsburgh, Pa (T.G.J.); Neurovascular Unit, Dept of Neurology, Hosp Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain (M.R.); Melbourne Brain Ctr, The Royal Melbourne Hosp, Univ of Melbourne, Australia (B.Y.); Dept of Radiology, Medical College of Wisconsin, Milwaukee, Wis (O.O.Z.); Colorado Neurologic Inst, Denver, Colo (D.F.); Dept of Neuroradiology, Dresden Univ Stroke Ctr, Univ Hosp, Dresden, Germany (R.v.K.); Dept of Neurosurgery, Radiology and Public Health Sciences, Penn State M.S. Hershey Medical Ctr, Hershey, Pa (K.C.); and UCLA Stroke Ctr, Los Angeles, Calif (D.S.L.)
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Mortimer AM, Bradley MD, Renowden SA. Endovascular therapy in hyperacute ischaemic stroke: history and current status. Interv Neuroradiol 2013; 19:506-18. [PMID: 24355158 DOI: 10.1177/159101991301900417] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 09/15/2013] [Indexed: 01/19/2023] Open
Abstract
This is a literature review on to the use of endovascular therapy in hyperacute ischaemic stroke secondary to large vessel occlusion (LVO). The prognosis for LVO is generally poor and the efficacy of intravenous tissue plasminogen activator (IV TPA) in the treatment of this subtype of stroke is questionable. It is well documented that recanalisation is associated with improved outcomes but IV TPA has limited efficacy in LVO recanalisation and the complication rates are higher for IV TPA in this stroke subset. Improved recanalisation rates have been demonstrated with intra-arterial TPA and first and second generation mechanical techniques but the rate of favourable outcome has not overtly mirrored this improvement. Several controversial trials using these early techniques have recently been published but fail to reflect modern practice which centres on the use of stent-retriever technology. This has been proven to be superior to older techniques. Not only are recanalisation rates higher, but the speed of recanalisation is greater and clinical results are improved. Multiple observational studies demonstrate consistently high rates of LVO recanalisation; TICI 2b/3 in the order of 65-95% and, rates of favourable outcome (mRS 0-2) in the order of 55% (42.5-77%) in clinically moderate to severe stroke with complicating symptomatic haemorrhage in the order of 1.5-15%. A major factor determining outcome is time to treatment but success has been demonstrated using these devices with bridging therapy, after IV TPA failure or as a stand-alone treatment.
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Affiliation(s)
- Alex M Mortimer
- Department of Neuroradiology, Frenchay Hospital; Bristol, United Kingdom -
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