MD Conference Express ISC 2012 - (Page 22)
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SELECTED UPDATES IN ACUTE ENDOVASCULAR TREATMENT
Acute Endovascular Treatment: From Target Mismatch to Clinical Scoring
Written by Rita Buckley
The use of multimodal imaging is increasing, with the hope that it will improve patient selection for endovascular stroke treatment. A recent post hoc analysis of the Interventional Management of Stroke I-II trial suggests a 12% decrease in the probability of a good outcome for every 30 minutes of delay from symptom onset to the initiation of endovascular treatment [Khatri P et al. Neurology 2009]. Rishi Gupta, MD, Emory School of Medicine, Atlanta, Georgia, USA, discussed the effects of time delays on outcomes and hemorrhage rates in patients who receive noncontrast computed tomography (NCCT) only or multimodal CT imaging. Patients with occlusion of the middle cerebral artery (MCA; M1 or M2) or internal carotid artery who were treated <8 hours from symptom onset were in a retrospective review of patients at eight tertiary stroke centers. From September 2009 to December 2011, a total of 594 patients were screened; 418 were included in the study. Data were collected on time points for every milestone, as well as on demographics, radiographic interpretation of hemorrhages, and reperfusion status. Infarct volume was calculated using summation of region of interest of each slice. Successful reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) score 2b or better. Asymptomatic hemorrhage was defined as H1, H12, or PH1, based on the European Cooperative Acute Stroke Study (ECASS) definition. Modified Rankin scale score at 90 days was used to assess outcomes from 0 to 2. Baseline demographics were comparable between the NCCT (n=227) and CT perfusion (n=191) groups, except patients in the NCCT group were noted to have a higher pretreatment NIHSS (19±6 vs 17±6; p<0.01). Patients who were undergoing CT perfusion prior to reperfusion had significantly longer times from CT acquisition to groin puncture (121±68 min vs 81±61 min; p<0.001) and from CT acquisition to reperfusion (223±89 min vs 175±94 min; p<0.001) compared with NCCT. There were no differences in good outcomes or intracranial hemorrhage between the two groups. Overall, use of multimodal CT imaging led to significant delays in acute endovascular care. Additional imaging did not translate to better clinical outcomes or reduce hemorrhagic rates. These results suggest that the streamlining of treatment will require rapid triage and that NCCT may be sufficient to select patients for endovascular therapy and achieve faster reperfusion. DEFUSE-2: Target Mismatch and Favorable Clinical Outcomes The DEFUSE-1 study identified a specific magnetic resonance imaging (MRI) profile (Target Mismatch [TMM]; Table 1) that is associated with benefit from reperfusion in IV tissue plasminogen activator (tPA)-treated patients. It was unknown whether local investigators in the acute setting could accurately determine a patient’s TMM status or if patients with that profile would respond more favorably to endovascular reperfusion than those without it. Table 1. Definition of TMM.
Variable TMM Criteria PWI (Tmax>6s)/DWI≥1.8 DWI <70 ml PWI (Tmax>10s) <100 ml AND AND
Peer-Reviewed Highlights from the
The aim of Diffusion-Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 [DEFUSE-2; NCT01349946] was to demonstrate that clinicians in the emergency
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Table of Contents for the Digital Edition of MD Conference Express ISC 2012
MD Conference Express ISC 2012
From Neurovascular Laboratory to Clinic: A Journey Through Time
No Compelling Evidence to Use Warfarin or Aspirin in Heart Failure Patients
AXIS 2 Clinical Outcomes No Different Than Placebo
SAMMPRIS: 30-Day Outcomes After Angioplasty and Stenting
Aggressive Medical Therapy Benefits Those Who Fail Antithrombotic Therapy
Initial Clinical Results with TREVO® Mechanical Thrombectomy Device are Promising
Linking sICH Definitions to Outcomes
Solitaire™ Flow Restoration Device Achieves Successful Recanalization Free of Symptomatic Hemorrhage Transformation
FIA II Seeks Genetic Underpinnings of Familial Intracranial Aneurysm
SPS3 Study Does Not Support the Use of Combination Therapy for Stroke Prevention
Novel Agent NA-1 Proves that Ischemic Neuroprotection is Possible in Older Patients
Acute Endovascular Treatment
Neuroimaging
Stroke Guidelines: Current Recommendations in Principle and Practice
The Rising Trend of Ischemic Stroke in the Young
Advanced Neuroimaging Adds Time, Reduces Endovascular Treatment in Clinical Practice
MD Conference Express ISC 2012
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