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  • 11
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    Prevalence and Significance of Impaired Microvascular Tissue Reperfusion Despite Macrovascular Angiographic Reperfusion (No-Reflow)
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Neurology Vol. 98, No. 8 ( 2022-02-22), p. e790-e801
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 98, No. 8 ( 2022-02-22), p. e790-e801
    Abstract: The relevance of impaired microvascular tissue-level reperfusion despite complete upstream macrovascular angiographic reperfusion (no-reflow) in human stroke remains controversial. We investigated the prevalence and clinical-radiologic features of this phenomenon and its associations with outcomes in 3 international randomized controlled thrombectomy trials with prespecified follow-up perfusion imaging. Methods In a pooled analysis of the Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial (EXTEND-IA; ClinicalTrials.gov NCT01492725), Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK; NCT02388061), and Determining the Optimal Dose of Tenecteplase Before Endovascular Therapy for Ischaemic Stroke (EXTEND-IA TNK Part 2; NCT03340493) trials, patients undergoing thrombectomy with final angiographic expanded Treatment in Cerebral Infarction score of 2c to 3 score for anterior circulation large vessel occlusion and 24-hour follow-up CT or MRI perfusion imaging were included. No-reflow was defined as regions of visually demonstrable persistent hypoperfusion on relative cerebral blood volume or flow maps within the infarct and verified quantitatively by 〉 15% asymmetry compared to a mirror homolog in the absence of carotid stenosis or reocclusion. Results Regions of no-reflow were identified in 33 of 130 patients (25.3%), encompassed a median of 60.2% (interquartile range 47.8%–70.7%) of the infarct volume, and involved both subcortical (n = 26 of 33, 78.8%) and cortical (n = 10 of 33, 30.3%) regions. Patients with no-reflow had a median 25.2% (interquartile range 16.4%–32.2%, p 〈 0.00001) relative cerebral blood volume interside reduction and 19.1% (interquartile range 3.9%–28.3%, p = 0.00011) relative cerebral blood flow reduction but similar mean transit time (median −3.3%, interquartile range −11.9% to 24.4%, p = 0.24) within the infarcted region. Baseline characteristics were similar between patients with and those without no-reflow. The presence of no-reflow was associated with hemorrhagic transformation (adjusted odds ratio [aOR] 1.79, 95% confidence interval [CI] 2.32–15.57, p = 0.0002), greater infarct growth (β = 11.00, 95% CI 5.22–16.78, p = 0.00027), reduced NIH Stroke Scale score improvement at 24 hours (β = −4.06, 95% CI 6.78–1.34, p = 0.004) and being dependent or dead at 90 days as assessed by the modified Rankin Scale (aOR 3.72, 95% CI 1.35–10.20, p = 0.011) in multivariable analysis. Discussion Cerebral no-reflow in humans is common, can be detected by its characteristic perfusion imaging profile using readily available sequences in the clinical setting, and is associated with posttreatment complications and being dependent or dead. Further studies evaluating the role of no-reflow in secondary injury after angiographic reperfusion are warranted. Classification of Evidence This study provides Class II evidence that cerebral no-reflow on CT/MRI perfusion imaging at 24 hours is associated with posttreatment complications and poor 3-month functional outcome.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000013210
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 12
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    Thrombectomy Outcomes With General vs Nongeneral Anesthesia : A Pooled Patient-Level Analysis From the EXTEND-IA Trials and SELECT Study
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Neurology Vol. 100, No. 3 ( 2023-01-17), p. e336-e347
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 100, No. 3 ( 2023-01-17), p. e336-e347
    Abstract: The effect of anesthesia choice on endovascular thrombectomy (EVT) outcomes is unclear. Collateral status on perfusion imaging may help identify the optimal anesthesia choice. Methods In a pooled patient-level analysis of EXTEND-IA, EXTEND-IA TNK, EXTEND-IA TNK part II, and SELECT, EVT functional outcomes (modified Rankin Scale score distribution) were compared between general anesthesia (GA) vs non-GA in a propensity-matched sample. Furthermore, we evaluated the association of collateral flow on perfusion imaging, assessed by hypoperfusion intensity ratio (HIR) – Tmax 〉 10 seconds/Tmax 〉 6 seconds (good collaterals – HIR 〈 0.4, poor collaterals – HIR ≥ 0.4) on the association between anesthesia type and EVT outcomes. Results Of 725 treated with EVT, 299 (41%) received GA and 426 (59%) non-GA. The baseline characteristics differed in presentation National Institutes of Health Stroke Scale score (median [interquartile range] GA: 18 [13–22] , non-GA: 16 [11–20], p 〈 0.001) and ischemic core volume (GA: 15.0 mL [3.2–38.0] vs non-GA: 9.0 mL [0.0–31.0] , p 〈 0.001). In addition, GA was associated with longer last known well to arterial access (203 minutes [157–267] vs 186 minutes [138–252] , p = 0.002), but similar procedural time (35.5 minutes [23–59] vs 34 minutes [22–54] , p = 0.51). Of 182 matched pairs using propensity scores, baseline characteristics were similar. In the propensity score–matched pairs, GA was independently associated with worse functional outcomes (adjusted common odds ratio [adj. cOR]: 0.64, 95% CI: 0.44–0.93, p = 0.021) and higher neurologic worsening (GA: 14.9% vs non-GA: 8.9%, aOR: 2.10, 95% CI: 1.02–4.33, p = 0.045). Patients with poor collaterals had worse functional outcomes with GA (adj. cOR: 0.47, 95% CI: 0.29–0.76, p = 0.002), whereas no difference was observed in those with good collaterals (adj. cOR: 0.93, 95% CI: 0.50–1.74, p = 0.82), p interaction : 0.07. No difference was observed in infarct growth overall and in patients with good collaterals, whereas patients with poor collaterals demonstrated larger infarct growth with GA with a significant interaction between collaterals and anesthesia type on infarct growth rate ( p interaction : 0.020). Discussion GA was associated with worse functional outcomes after EVT, particularly in patients with poor collaterals in a propensity score–matched analysis from a pooled patient-level cohort from 3 randomized trials and 1 prospective cohort study. The confounding by indication may persist despite the doubly robust nature of the analysis. These findings have implications for randomized trials of GA vs non-GA and may be of utility for clinicians when making anesthesia type choice. Classification of Evidence This study provides Class III evidence that use of GA is associated with worse functional outcome in patients undergoing EVT. Trial Registration Information EXTEND-IA: ClinicalTrials.gov (NCT01492725); EXTEND-IA TNK: ClinicalTrials.gov (NCT02388061); EXTEND-IA TNK part II: ClinicalTrials.gov (NCT03340493); and SELECT: ClinicalTrials.gov (NCT02446587).
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000201384
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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  • 13
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    Association between pre-treatment perfusion profile and cerebral edema after reperfusion therapies in ischemic stroke
    SAGE Publications ; 2021
    In:  Journal of Cerebral Blood Flow & Metabolism Vol. 41, No. 11 ( 2021-11), p. 2887-2896
    Details
    In: Journal of Cerebral Blood Flow & Metabolism, SAGE Publications, Vol. 41, No. 11 ( 2021-11), p. 2887-2896
    Abstract: The relationship between reperfusion and edema is unclear, with experimental and clinical data yielding conflicting results. We investigated whether the extent of salvageable and irreversibly-injured tissue at baseline influenced the effect of therapeutic reperfusion on cerebral edema. In a pooled analysis of 415 patients with anterior circulation large vessel occlusion from the Tenecteplase-versus-Alteplase-before-Endovascular-Therapy-for-Ischemic-Stroke (EXTEND-IA TNK) part 1 and 2 trials, associations between core and mismatch volume on pre-treatment CT-Perfusion with cerebral edema at 24-hours, and their interactions with reperfusion were tested. Core volume was associated with increased edema (p  〈  0.001) with no significant interaction with reperfusion (p = 0.82). In comparison, a significant interaction between reperfusion and mismatch volume (p = 0.03) was observed: Mismatch volume was associated with increased edema in the absence of reperfusion (p = 0.009) but not with reperfusion (p = 0.27). When mismatch volume was dichotomized at the median (102 ml), reperfusion was associated with reduced edema in patients with large mismatch volume (p  〈  0.001) but not with smaller mismatch volume (p = 0.35). The effect of reperfusion on edema may be variable and dependent on the physiological state of the cerebral tissue. In patients with small to moderate ischemic core volume, the benefit of reperfusion in reducing edema is related to penumbral salvage.
    Type of Medium: Online Resource
    ISSN: 0271-678X , 1559-7016
    URL: Article
    DOI: 10.1177/0271678X211017696
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2021
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  • 14
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    The Association between Lesion Location and Functional Outcome after Ischemic Stroke
    SAGE Publications ; 2015
    In:  International Journal of Stroke Vol. 10, No. 8 ( 2015-12), p. 1270-1276
    Details
    In: International Journal of Stroke, SAGE Publications, Vol. 10, No. 8 ( 2015-12), p. 1270-1276
    Abstract: Infarct location has a critical effect on patient outcome after ischemic stroke, but the study of its role independent of overall lesion volume is challenging. We performed a retrospective, hypothesis-generating study of the effect of infarct location on three-month functional outcome in a pooled analysis of the EPITHET and DEFUSE studies. Methods Posttreatment MRI diffusion lesions were manually segmented and transformed into standard-space. A novel composite brain atlas derived from three standard brain atlases and encompassing 132 cortical and sub-cortical structures was used to segment the transformed lesion into different brain regions, and calculate the percentage of each region infarcted. Classification and Regression Tree (CART) analysis was performed to determine the important regions in each hemisphere associated with nonfavorable outcome at day 90 (modified Rankin score [mRS] 〉 1). Results Overall, 152 patients (82 left hemisphere) were included. Median diffusion lesion volume was 37·0 ml, and median baseline National Institutes of Health Stroke Score was 13. In the left hemisphere, the strongest determinants of nonfavorable outcome were infarction of the uncinate fasciculus, followed by precuneus, angular gyrus and total diffusion lesion volume. In the right hemisphere, the strongest determinants of nonfavorable outcome were infarction of the parietal lobe followed by the putamen. Conclusions Assessment of infarct location using CART demonstrates regional characteristics associated with poor outcome. Prognostically important locations include limbic, default-mode and language areas in the left hemisphere, and visuospatial and motor regions in the right hemisphere.
    Type of Medium: Online Resource
    ISSN: 1747-4930 , 1747-4949
    URL: Article
    DOI: 10.1111/ijs.12537
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
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  • 15
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    Abstract 052: External Validation of the Prediction Model For Delayed Reperfusion in Patients with Incomplete Reperfusion: EXTEND‐PROCEED
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke: Vascular and Interventional Neurology Vol. 3, No. S2 ( 2023-11)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 3, No. S2 ( 2023-11)
    Abstract: The benefit of additional reperfusion attempts in patients with partial angiographic reperfusion (TICI2b) is unknown. The PROCEED model predicts subsequent favorable occurrence of complete reperfusion (i.e. delayed reperfusion [DR]) at 24 hours after initial incomplete angiographic reperfusion at the conclusion of thrombectomy. This study aims to externally validate the PROCEED model using pooled data from multiple international trials that systematically performed follow‐up perfusion imaging. Methods Individual patient data for external validation were obtained from the EXTEND‐IA, EXTEND‐IA TNK part 1 and 2 trials (clinicaltrials.gov, unique‐identifier: NCT01492725, NCT02388061 and NCT03340493). The model’s primary outcome of interest was the occurrence of DR, defined as the absence of any focal perfusion deficit on follow‐up CT or MRI perfusion imaging maps, despite initial incomplete angiographic reperfusion on the final thrombectomy angiography series. The updated model’s performance was evaluated with discrimination, calibration and clinical decision curves. Results We analyzed 267 patients for the external validation, with median age of 74 (IQR 64 – 80), 44.2% were female and 62% had DR. The externally validated model had good discrimination (C‐statistic 0.81, 95% CI 0.72 – 0.86) and was well calibrated (intercept 0.22, 95% CI 0.18‐0.33 and slope 0.96, 95% CI 0.81‐1.23). With threshold probability of R=12% (i.e. 88% chance of having DR), pursuing additional reperfusion attempts to pursue complete angiographic reperfusion in a patient with high‐likelihood of DR were seven times worse (Cost:Benefit Ratio 1:7, Figure 1) than no further endovascular maneuver. In terms of standardized net reduction, the PROCEED model could reduce one in five unnecessary interventions without missing an intervention for any patient who would eventually have DR. Across a wide range of threshold probabilities, the model outperformed the scenario of the typical decision‐making process in the angiography suite, based on the current treatment guidelines. Conclusion The externally validated model had good predictive accuracy and discrimination. Depending on the acceptable risk threshold, the model may compliment clinical judgment of the treating physicians and inform on natural progression of untreated incomplete reperfusion.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.03.suppl_2.052
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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  • 16
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    Abstract 113: CT Perfusion Mismatch Identifies More Thrombectomy Patients Than Clinical Core Mismatch
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. Suppl_1 ( 2018-01-22)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. Suppl_1 ( 2018-01-22)
    Abstract: Background: Following DAWN and DEFUSE 3, optimal imaging selection of large vessel ischemic stroke patients for thrombectomy 〉 6h is important. We hypothesized that perfusion mismatch used in EXTEND-IA and DEFUSE 3 would identify more patients eligible for thrombectomy than clinical-core mismatch used in DAWN. Methods: Prospectively collected data were analyzed for acute ischemic stroke patients aged 〉 18 with pre-treatment whole brain CT perfusion from 2012-2017 at a comprehensive stroke center. CTP was omitted 〉 6h in patients with extensive CT hypodensity. We compared the proportion of patients with anterior circulation large vessel occlusion (ICA, M1 and tandem occlusions) who fulfilled criteria for DAWN (clinical-core mismatch: age 〈 80 & NIHSS≥20 with 〈 51mL core, age 〈 80 & NIHSS10-19 with 〈 31mL core, age 〉 80 & NIHSS 〉 10 with 〈 21mL core), DEFUSE3 (mismatch ratio 〉 1.8, mismatch 〉 15mL, core 〈 70mL, age 〈 91, NIHSS 〉 5) and EXTEND-IA (mismatch ratio 〉 1.2, mismatch 〉 10mL, core 〈 70mL, no age or NIHSS limits). Pre-morbid function, alteplase eligibility and tandem occlusion trial exclusions were not applied to emulate clinical practice. Independent functional outcome was defined as 90 day mRS 0-2. Results: Of 982 ischemic stroke patients evaluated with pre-treatment CTP, 291 had large vessel occlusion. Within 6h of stroke onset, 175/231 (76%) patients met EXTEND-IA criteria compared to 153/231 (60%) DEFUSE3 and 96/231 (42%) DAWN, p 〈 0.0001 for all comparisons. Beyond 6h after onset, 39/58 (67%) met EXTEND-IA mismatch criteria compared to 33/58 (57%) DEFUSE 3 criteria and 26/58 (45%) DAWN criteria, p 〈 0.0001 for all comparisons. Overall 4 patients with clinical-core mismatch did not meet perfusion mismatch criteria. Patients eligible for DEFUSE3 but not DAWN achieved independence in 48% vs 40% in those eligible for both studies, OR 2.1 95%CI 0.9-5.0, p=0.09 in logistic regression adjusted for age and NIHSS. Similar findings applied to patients eligible for EXTEND-IA but not DAWN. Conclusions: Perfusion mismatch selection would lead to substantially more patients receiving thrombectomy than clinical-core mismatch. These patients were generally older with milder NIHSS, but had similar probability of independent outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.113
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 17
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    Abstract 100: Reperfusion Improves Clinical Outcome Across the 4.5-9h and Wake-Up Stroke Time Continuum in EXTEND and EPITHET
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Introduction: Intravenous alteplase reduces disability after ischemic stroke in patients 4.5-9h after onset and with wake-up onset stroke who have favorable perfusion imaging. We examined the benefit of reperfusion in reducing disability, including by onset to randomization time strata in the EXTEND and EPITHET randomized trials. Methods: Patients were randomized to alteplase or placebo after perfusion mismatch imaging. Reperfusion was defined as 〉 90% reduction in Tmax 〉 6s lesion volume at 24h. Ordinal logistic regression adjusted for baseline age and NIHSS was used to analyze functional improvement in day 90 modified Rankin scale overall, including a reperfusion*time to randomization interaction term, and in the 4.5-6h, 6-9h and wake-up time strata. Symptomatic hemorrhage was defined as large parenchymal hematoma with ≥4 point NIHSS increase (SITS). Results: Reperfusion was assessable in 270/294 (92%) patients, 68/133 (51%) alteplase and 38/137 (28%) placebo reperfused (p 〈 0.001). Median age 76 (IQR 66-81) in reperfused vs 74 (IQR 64.5-81) in non-reperfused, median baseline NIHSS 10 (IQR 7-15) in reperfused vs 12 (IQR 8-17.5) in non-reperfused. Overall, reperfusion was associated with common odds ratio 7.7 (95%CI 4.6-12.8, p 〈 0.0001) in ordinal “shift” analysis. There was no heterogeneity in the beneficial effect of reperfusion effect by time to randomization (p=0.63). Reperfusion was associated with significantly improved functional outcome in each of the 4.5-6h, 6-9h and wake-up time strata (figure). Symptomatic hemorrhage, assessed in all 294 patients, occurred in 3/51 (5.9%) 4.5-6h, 2/28 (7.1%) 6-9h, 4/73 (5.5%) wake-up stroke in the alteplase-treated patients (van Elteren p=0.66). Conclusions: Strong benefits of reperfusion in all time strata without differential risk in symptomatic hemorrhage support the durable treatment effect of alteplase in perfusion mismatch-selected patients throughout the 4.5-9h and wake-up stroke time window.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.100
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 18
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    Abstract WP33: Reduced Cerebral Blood Flow on Acute Whole Brain CT Perfusion Best Predicts Hemorrhagic Transformation
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Objective: Hemorrhagic transformation in ischemic stroke is a potentially life threatening complication of thrombolysis. Using perfusion MRI, very low cerebral blood volume (VLCBV) strongly predicts hemorrhagic transformation after reperfusion. CT perfusion (CTP) is currently more widely accessible than MRI and recent data have shown that CT relative cerebral blood flow (relCBF) provides a better estimate of infarct core than CBV. We aimed to determine the optimal parameter to predict hemorrhagic transformation using whole brain CTP. Methods: Patients with ischemic stroke were imaged with whole brain CTP within 6hrs of symptom onset. Hemorrhagic transformation was assessed on CT/MRI within 7 days of stroke using ECASS grade. CBF and CBV were analyzed within a relative time to peak 〉 4sec region of interest. Results were expressed as volumes below a given percentile relative to the contralateral hemisphere (relCBF and relCBV). Receiver operating characteristic (ROC) and logistic regression analysis were performed to determine the optimal parameter and percentile threshold correlating with parenchymal hemorrhage (PH). Results: 128 patients with acute CTP were analyzed, median age 76yr (IQR 66-83), median NIHSS 13 (IQR 9-16), 59% received IV thrombolysis. 11 patients had PH on follow-up. On ROC analysis, the optimal threshold for very low CBF (VLCBF) was at the 〈 0 th centile. VLCBF was significantly associated with PH in ROC analysis (AUC=0.760, p 〈 0.01) whereas VLCBV (AUC 0.638 at 〈 5 th centile, 0.618 at 〈 2.5 th centile, 0.440 at 〈 0 th centile) was not significant. Using VLCBF, the optimal lesion volume to predict PH was 〉 3mL with OR 12.0 (95%CI 2.4-58), sensitivity 0.82 (95%CI 0.48-0.98), specificity 0.73 (95%CI 0.64-0.80), negative predictive value 0.98 (95%CI 0.92-1.0) and positive predictive value 0.22 (95%CI 0.11-0.38). In logistic regression, PH was associated with increased VLCBF (p 〈 0.01) but not with VLCBV (p=0.08). The Bayesian information criterion for VLCBF compared to VLCBV was +5 indicating improved model fit. Conclusions: VLCBF appears to be more reliably associated with hemorrhagic transformation than VLCBV when CT perfusion is used. This may be due to reduced ability of VLCBV to distinguish regions of ischemia from normal white matter.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.AWP33
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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  • 19
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    Abstract WP45: Comparison of Automated Whole Brain CT Perfusion Analysis with Perfusion-Diffusion MRI in Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Background and purpose: CT perfusion (CTP) provides rapid and accessible imaging of ischemic stroke pathophysiology. Studies with limited brain coverage CTP have suggested that relative cerebral blood flow (relCBF) is the optimal CTP parameter to define irreversible infarction. We analyzed patients with whole brain CT perfusion and contemporaneous MR perfusion-diffusion imaging to confirm the optimal CTP parameter for infarct core and compare mismatch classification between MR and CT. Methods: Acute ischemic stroke patients 〈 6hr after onset had whole brain CTP (320slice) closely followed by perfusion-diffusion MRI. Maps of CBF, CBV and time-to-peak of the deconvolved tissue residue function (Tmax) were generated by RAPID automated perfusion analysis software (Stanford University) using delay insensitive deconvolution. The optimal CTP map to identify infarct core was selected by maximizing the average Dice co-efficient across the same threshold range for all patients using co-registered diffusion lesion (manually outlined to its maximal visual extent) as reference region. Mismatch classification agreement between CT and MRI was then assessed using 2 definitions: mismatch ratio a) 〉 1.2 or b) 〉 1.8, absolute mismatch a) 〉 10mL or b) 〉 15mL, infarct core 〈 70mL. Results: In 28 patients imaged 〈 6hr from stroke onset (median age 69, median onset to CT 180min, median CT to MR 69min), relCBF provided the most accurate estimate for infarct core, significantly better than absolute or relative CBV (both p 〈 0.001). Using relCBF to generate acute CTP infarct core volumes, the median magnitude of volume difference versus diffusion MR was 6.9mL, interquartile range 1.6-27.4mL. CTP mismatch between relCBF core and Tmax 〉 6sec perfusion lesion was assessed in 25 patients (3/28 had no MR perfusion). CTP and MR perfusion-diffusion mismatch classification agreed in 23/25 (92%) patients (kappa 0.84) using either definition. Conclusions: This study using whole brain CTP confirms the greater accuracy of CBF over CBV for estimation of the infarct core. The 〉 90% agreement in mismatch classification between CTP and MRI supports the concept that both modalities can identify similar patient populations for clinical trials of reperfusion therapies.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.AWP45
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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  • 20
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    Tenecteplase Treatment and Thrombus Characteristics Associated With Early Reperfusion: An EXTEND-IA TNK Trials Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. 3 ( 2023-03), p. 706-714
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. 3 ( 2023-03), p. 706-714
    Abstract: Intracranial occlusion site, contrast permeability, and clot burden are thrombus characteristics that influence alteplase-associated reperfusion. In this study, we assessed the reperfusion efficacy of tenecteplase and alteplase in subgroups based on these characteristics in a pooled analysis of the EXTEND-IA TNK trial (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke). Methods: Patients with large vessel occlusion were randomized to treatment with tenecteplase (0.25 or 0.4 mg/kg) or alteplase before thrombectomy in hospitals across Australia and New Zealand (2015–2019). The primary outcome, early reperfusion, was defined as the absence of retrievable thrombus or 〉 50% reperfusion on first-pass angiogram. We compared the effect of tenecteplase versus alteplase overall, and in subgroups, based on the following measured with computed tomography angiography: intracranial occlusion site, contrast permeability (measured via residual flow grades), and clot burden (measured via clot burden scores). We adjusted for covariates using mixed effects logistic regression models. Results: Tenecteplase was associated with higher odds of early reperfusion (75/369 [20%] versus alteplase: 9/96 [9%] , adjusted odds ratio [aOR], 2.18 [95% CI, 1.03–4.63] ). The difference between thrombolytics was notable in occlusions with low clot burden (tenecteplase: 66/261 [25%] versus alteplase: 5/67 [7%] , aOR, 3.93 [95% CI, 1.50–10.33]) when compared to high clot burden lesions (tenecteplase: 9/108 [8%] versus alteplase: 4/29 [14%], aOR, 0.58 [95% CI, 0.16–2.06] ; P interaction =0.01). We did not observe an association between contrast permeability and tenecteplase treatment effect (permeability present: aOR, 2.83 [95% CI, 1.00–8.05] versus absent: aOR, 1.98 [95% CI, 0.65–6.03] ; P interaction =0.62). Tenecteplase treatment effect was superior with distal M1 or M2 occlusions (53/176 [30%] versus alteplase: 4/42 [10%] , aOR, 3.73 [95% CI, 1.25–11.11]), but both thrombolytics had limited efficacy with internal carotid artery occlusions (tenecteplase 1/73 [1%] versus alteplase 1/19 [5%], aOR, 0.22 [95% CI, 0.01–3.83] ; P interaction =0.16). Conclusions: Tenecteplase demonstrates superior early reperfusion versus alteplase in lesions with low clot burden. Reperfusion efficacy remains limited in internal carotid artery occlusions and lesions with high clot burden. Further innovation in thrombolytic therapies are required.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.122.041061
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    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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