Mechanical embolectomy for acute ischemic stroke beyond six hours from symptom onset using MRI based perfusion imaging

• Published in: Journal of the neurological sciences 2017-04, Vol.375, p.395-400
• Main Authors: McTaggart, Ryan A, Yaghi, Shadi, Sacchetti, Daniel C, Haas, Richard A, Hemendinger, Morgan, Arcuri, Daniel, Rogg, Jeffrey M, Furie, Karen L, Jayaraman, Mahesh V
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Brain Ischemia - complications; Cerebral Angiography; Embolectomy - methods; Female; Follow-Up Studies; Humans; Image Processing, Computer-Assisted; Imaging; Magnetic Resonance Angiography; Male; Middle Aged; MRI; Neurology; Outcome; Perfusion; Severity of Illness Index; Stroke; Stroke - diagnostic imaging; Stroke - etiology; Stroke - surgery; Thrombectomy; Treatment Outcome; Treatment window
• ISSN: 0022-510X; 1878-5883
• DOI: 10.1016/j.jns.2017.02.044

Abstract Introduction There is very limited data on the use of MRI based perfusion imaging to select patients with acute ischemic stroke and large vessel occlusion (LVO) for intraarterial therapy beyond 6 h from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 h from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods This is a single institution (Rhode Island Hospital) retrospective study between December 1st, 2015, and July 30th, 2016 that included patients with acute ischemic stroke and proximal LVO with CT ASPECTS of 6 or more and 6–24 h from symptom onset who were assessed for mechanical embolectomy using MRI based perfusion imaging. Favorable imaging profile was defined based on prior studies as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 × 10–6 mm2 /s) of 70 ml or less; 2) Penumbra volume (as defined by volume of tissue with Tmax > 6 s) of 15 ml or greater; 3) A mismatch ratio of 1.8 or more; and 4) Volume of tissue with perfusion lesion with Tmax > 10 s is < 100 ml. Good outcome was defined as a 90-day mRS ≤ 2. Results 41 patients met the inclusion criteria; 22 (53.7%) had favorable imaging profile and underwent mechanical embolectomy. The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (63.6% vs. 46%, p = 0.13). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusions MRI perfusion based imaging may help select patients with acute ischemic stroke and proximal emergent LVO for embolectomy beyond the treatment window used in most endovascular trials. This provides compelling evidence for stroke centers to participate in ongoing trials using advanced imaging to study endovascular treatment in this patient population.