With patient selection informed by multiphase CT angiography and ASPECTS, late stroke treatment works for many, researchers report.

 

Using multiphase CT angiography and ASPECTS to guide patient selection, interventionalists in Dublin have been able to obtain good outcomes using endovascular therapy for the treatment of stroke even when more than 12 hours have passed. A retrospective analysis of their experience was published online February 19, 2018, in the Journal of NeuroInterventional Surgery.

 

“With the emergence of data supporting endovascular thrombectomy as an effective intervention outside conventional therapeutic time windows in selected patients following proximal anterior circulation ischemic stroke, we felt it was important to review the outcomes achieved by our stroke network,” Ronan Motyer, MD (Beaumont Hospital, Dublin, Ireland), told Neurovascular Exchange in an email.

 

“Furthermore, our approach to patient selection differs to that of DAWN and DEFUSE 3, with these studies using perfusion-based imaging techniques to select patients. Similar to ESCAPE, our patient selection was guided by ASPECTS from non-contrast CT brain and collateral status on multiphase CT angiogram.”

 

Motyer and colleagues conducted a retrospective review of all 25 cases of endovascular therapy performed at their institution for the treatment of proximal anterior circulation acute ischemic stroke that had an onset of more than 12 hours earlier. These 25 cases comprised 4.6% of the 542 consecutive endovascular stroke therapy cases that were performed between April 2014 and July 2017.

 

Patients’ median age was 69 years, and their median NIHSS score on presentation was 14 (IQR 11-18.5). Median ASPECTS was 8 (IQR 8-9), and 96% had moderate-to-good collateral status. The median time to groin puncture was 14 hours and 40 minutes.

 

Rates of successful recanalization, defined as mTICI 2b-3, and functional independence at 90 days, defined as an mRS 0-2, were both good at 88% and 52%, respectively. There were no episodes of symptomatic intracranial hemorrhage, and the 90-day mortality rate was 12%.

 

Does CT Angiography Add to ASPECTS?

 

Commenting on the study for NVX, Tudor G. Jovin, MD (UPMC Stroke Institute, Pittsburgh, PA), expressed surprise that the authors only looked at outcomes among patients treated more than 12 hours after stroke onset, rather than past the standard 6-hour time window.

 

Motyer explained that they chose this time window because the ESCAPE trial, which employed a similar paradigm to patient selection, “has demonstrated benefit for endovascular thrombectomy up to 12 hours from symptom onset. A recently performed and published subgroup analysis on their early and late presenters shows no significant difference in outcomes between groups.” Moreover, he and his colleagues recently compared outcomes for time windows of less than 6 hours, more than 6 hours, and more than 7.3 hours after symptoms appeared, finding no difference among these groups.

 

“The safety data are very strong,” said Jovin, “and the clinical outcomes are similar to DAWN and DEFUSE 3, even when you don’t select patients based on . . . advanced imaging, such as CT perfusion and MRI, using software that measures the volume of infarct.” He added that such findings are important because many centers around the world lack round-the-clock availability of advanced imaging techniques, and software such as RAPID also remains out of reach.

 

But Jovin questioned whether multiphase CT angiography added more clinical decision-making value above simply using ASPECTS score.

 

For his part, Motyer remains convinced that multiphase CT angiography does provide important additional information. “The role CTA plays in demonstrating neuroanatomy and confirming large vessel occlusion [is] essential in determining eligibility for intervention,” he noted. "The additional phases may be performed easily, with no extra contrast required, enable calculation of collateral status, [and] may better demonstrate perfusion in patients with poor collateral flow on single-phase. Multiphase CTA therefore enables inference of penumbra which may potentially be salvaged with intervention.”

 

Both interventionalists agreed that multicenter, controlled trials are needed to confirm the precise criteria required to accurately select patients likely to benefit from late endovascular interventions.

 


Source:

Motyer R, Thornton J, Power S, et al. Endovascular thrombectomy beyond 12 hours of stroke onset: a stroke network's experience of late intervention. J NeuroInterv Surg. 2018;Epub ahead of print.

 

Disclosures:

 

Motyer and Jovin report no relevant conflicts of interest.