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Severe hypoperfusion in the absence of a large ischemic core should not exclude patients from reperfusion therapies.

Authors :
Bladin C.F.
Davis S.M.
Campbell B.C.V.
Mitchell P.J.
Kleinig T.J.
Dewey H.M.
Churilov L.
Parsons M.W.
Brooks M.
Miteff F.
Krause M.
Harrington T.J.
Scroop R.
Barber P.A.
McGuinness B.
Wijeratne T.
Phan T.G.
Chong W.
Donnan G.A.
Badve M.
Bladin C.F.
Davis S.M.
Campbell B.C.V.
Mitchell P.J.
Kleinig T.J.
Dewey H.M.
Churilov L.
Parsons M.W.
Brooks M.
Miteff F.
Krause M.
Harrington T.J.
Scroop R.
Barber P.A.
McGuinness B.
Wijeratne T.
Phan T.G.
Chong W.
Donnan G.A.
Badve M.
Publication Year :
2015

Abstract

Background: Optimal imaging selection for endovascular therapy for ischemic stroke remains controversial with a range of criteria used in the recent positive trials. Large volume severe hypoperfusion (Tmax > 10 s) is one such criterion, with optimal threshold > 82 mL ('malignant profile'), in a previous study. We examined whether this was associated with poor response to reperfusion in the EXTEND-IA randomized trial, which did not exclude patients on this basis. Method(s): Patients receiving tPA < 4.5 h with major vessel occlusion and favourable CT-perfusion (CTP) were randomised (after written informed consent, IRB-approved) to thrombectomy after tPA versus tPA-alone. CTP eligibility required mismatch ratio > 1.2 between hypoperfused tissue (Tmax > 6 s) and irreversibly injured ischemic core (relative cerebral blood flow <30%), absolute mismatch > 10 mL, ischemic core <70 mL (RAPID software, Stanford University). Tmax > 10 s volume was calculated and effect on clinical outcomes examined. Result(s): There were 70 patients, 35 in each arm, mean age = 69, median NIHSS = 15. In these patients with ischemic core <70 mL, median Tmax > 10 s volume was 41 mL with 12/70(17%) > 82 mL, 6/70(8.6%) > 100 mL. Of the 'malignant' patients(Tmax10s > 82 mL), 6/12(50%) had >90% reperfusion at 24 h (4 endovascular and 2 tPAonly), all of whom had 'early neurological recovery' (>=8 point NIHSS reduction or 0-1 by day 3) and 5/6(83%) had 90 day mRS0-1. No patient with <90% reperfusion had day 90 mRS < 3. Conclusion(s): In ischemic stroke patients <4.5 h after onset, large Tmax > 10 s volume in the absence of a large ischemic core was uncommon. Although the numbers in this study were small, the 83% rate of excellent functional outcome after reperfusion suggests that excluding such patients from therapy may not be justified.

Details

Database :
OAIster
Publication Type :
Electronic Resource
Accession number :
edsoai.on1305113135
Document Type :
Electronic Resource