Advertisement

Perfusion Imaging Collateral Scores Predict Infarct Growth in Non-Reperfused DEFUSE 3 Patients

      Abstract

      Objective

      This study evaluated the associations of perfusion imaging collateral profiles with radiographic and clinical outcome in late presenting, non-reperfused patients in the DEFUSE 3 clinical trial.

      Methods

      Non-reperfused patients in both treatment arms were included. Baseline ischemic core, Tmax >6s, and Tmax >10s perfusion volumes were calculated with RAPID software; infarct volumes obtained 24 hours after randomization were manually determined from DWI or CT. Substantial infarct growth was defined as a >25mL increase between baseline and 24-hour follow-up. Hypoperfusion Intensity Ratio (HIR) was defined as the proportion of the Tmax >6s lesion with Tmax >10s delay; CBV index was calculated by RAPID from mean CBV values within the Tmax >6s lesion compared to regions of normal CBV.

      Results

      Eighty-four patients were included. ROC analysis showed HIR ≥0.34 (AUC=0.68) and CBV index ≤0.74 (AUC=0.72) optimally predicted substantial infarct growth in follow-up. Median growth was 23.4 versus 73.2mL with HIR threshold of 0.34 (p=0.005), and 24.3 versus 58.7mL with CBV index threshold of 0.74 (p=0.004). If baseline HIR and CBV index were both favorable, median growth was 21.7mL, 40.9mL if one was favorable, and 108.2mL if both were unfavorable (p<0.001). Baseline perfusion profile was not associated with 90-day functional outcome.

      Conclusions

      Perfusion collateral scores forecast infarct growth in late presenting, non-reperfused ischemic stroke patients. These parameters may be useful for guiding transfer decisions, such as need for repeat imaging upon thrombectomy center arrival, and may help identify slow progressing patients more likely to have persistent salvageable ischemic tissue beyond 24 hours.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Powers WJ
        • Rabinstein AA
        • Ackerson T
        • et al.
        2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2018; 49: e46-e110
        • Bang OY
        • Saver JL
        • Kim SJ
        • et al.
        Collateral flow predicts response to endovascular therapy for acute ischemic stroke.
        Stroke. 2011; 42: 693-699
        • Liebeskind David S.
        • Tomsick Thomas A.
        • Foster Lydia D.
        • et al.
        Collaterals at angiography and outcomes in the Interventional Management of Stroke (IMS) III trial.
        Stroke. 2014; 45: 759-764
        • Marks MP
        • Lansberg MG
        • Mlynash M
        • et al.
        Effect of collateral blood flow on patients undergoing endovascular therapy for acute ischemic stroke.
        Stroke. 2014; 45: 1035-1039
        • Vagal A
        • Aviv R
        • Sucharew H
        • et al.
        Collateral clock is more important than time clock for tissue fate.
        Stroke. 2018; 49: 2102-2107
        • Albers GW.
        Late window paradox.
        Stroke. 2018; 49: 768-771
        • Mlynash M
        • Lansberg MG
        • De Silva DA
        • et al.
        Refining the definition of the malignant profile: insights from the DEFUSE-EPITHET pooled data set.
        Stroke. 2011; 42: 1270-1275
        • Olivot JM
        • Mlynash M
        • Inoue M
        • et al.
        Hypoperfusion intensity ratio predicts infarct progression and functional outcome in the DEFUSE 2 Cohort.
        Stroke. 2014; 45: 1018-1023
        • Arenillas JF
        • Cortijo E
        • García-Bermejo P
        • et al.
        Relative cerebral blood volume is associated with collateral status and infarct growth in stroke patients in SWIFT PRIME.
        J Cereb Blood Flow Metab Off J Int Soc Cereb Blood Flow Metab. 2018; 38: 1839-1847
        • Guenego A
        • Fahed R
        • Albers GW
        • et al.
        Hypoperfusion intensity ratio correlates with angiographic collaterals in acute ischaemic stroke with M1 occlusion.
        Eur J Neurol. 2020; 27: 864-870
        • Federau C
        • Mlynash M
        • Christensen S
        • et al.
        Evolution of Volume and Signal Intensity on Fluid-attenuated Inversion Recovery MR Images after Endovascular Stroke Therapy.
        Radiology. 2016; 280: 184-192
        • Albers GW
        • Lansberg MG
        • Kemp S
        • et al.
        A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3).
        Int J Stroke Off J Int Stroke Soc. 2017; 12: 896-905
        • Albers GW
        • Marks MP
        • Kemp S
        • et al.
        Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.
        N Engl J Med. 2018; 378: 708-718
        • Lansberg MG
        • Straka M
        • Kemp S
        • et al.
        MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study.
        Lancet Neurol. 2012; 11: 860-867
        • Lansberg MG
        • Christensen S
        • Kemp S
        • et al.
        CT Perfusion to Predict Response to Recanalization in Ischemic Stroke.
        Ann Neurol. 2017; 81: 849-856
        • Nogueira RG
        • Jadhav AP
        • Haussen DC
        • et al.
        Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.
        N Engl J Med. 2018; 378: 11-21
        • Goyal M
        • Menon BK
        • van Zwam WH
        • et al.
        Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.
        Lancet Lond Engl. 2016; 387: 1723-1731
        • Guenego A
        • Marcellus DG
        • Martin BW
        • et al.
        Hypoperfusion Intensity Ratio Is Correlated With Patient Eligibility for Thrombectomy.
        Stroke. 2019; 50: 917-922
        • Guenego A
        • Mlynash M
        • Christensen S
        • et al.
        Hypoperfusion ratio predicts infarct growth during transfer for thrombectomy.
        Ann Neurol. 2018; 84: 616-620
        • Søren Christensen
        • Michael Mlynash
        • Stephanie Kemp
        • et al.
        Persistent Target Mismatch Profile >24 Hours After Stroke Onset in DEFUSE 3.
        Stroke. 2019; 50: 754-757
        • Lansberg MG
        • O'Brien MW
        • Tong DC
        • et al.
        Evolution of cerebral infarct volume assessed by diffusion-weighted magnetic resonance imaging.
        Arch Neurol. 2001; 58: 613-617
        • Federau C
        • Christensen S
        • Mlynash M
        • et al.
        Comparison of stroke volume evolution on diffusion-weighted imaging and fluid-attenuated inversion recovery following endovascular thrombectomy.
        Int J Stroke Off J Int Stroke Soc. 2017; 12: 510-518
        • Wheeler HM
        • Mlynash M
        • Inoue M
        • et al.
        The growth rate of early DWI lesions is highly variable and associated with penumbral salvage and clinical outcomes following endovascular reperfusion.
        Int J Stroke Off J Int Stroke Soc. 2015; 10: 723-729