Application of non-contrasted computed tomography and diffusion-weighted imaging protocols for endovascular treatment selection in patients with late-presenting or wake-up strokes

ABSTRACT

Background: Among patients with acute ischemic stroke with a mismatch between deficit severity and infarct volume, thrombectomy performed within a 6-24 hours time window has efficacy and safety similar to treatment within 6 hours. However, whether magnetic resonance imaging with T2 diffusion-weighted imaging (DWI) is feasible remains to be validated. Objective: To investigate prognosis among stroke patients receiving endovascular treatment (EVT) within 6 hours and 6-24 hours using non-contrasted computed tomography (NCCT) and DWI. Methods: Overall, 209 anterior-circulation ischemic stroke patients with large-vessel occlusion who underwent EVT were divided into ≤ 6 hours and 6-24 hours groups. Patients presenting symptoms within 6 hours were treated if their NIHSS score was ≥ 7 and ASPECTS score was ≥ 5, whereas those with wake-up stroke (WUS) or presenting symptoms 6-24 hours after last seen well (WUS/late-presenting stroke, LPS) were managed if their NIHSS score was ≥ 7 and ASPECTS score was ≥ 5. Results: The percentages of patients undergoing intracranial stenting and intracranial ballooning without stenting significantly differed between two groups (p < 0.001). Grades 0, 1, 2a and 2b recanalization rates did not differ between the 6 hours and 6-24 hours groups (all p > 0.05). Grade 3 recanalization rate in the 6 hours group was significantly lower than in the 6-24 hours group (p = 0.043). The 3-month Rankin Scale score did not significantly differ between the two groups (p = 0.629). Conclusions: EVT is a safe and effective treatment for patients with WUS and LPS selected through NCCT and DWI-based simple imaging.

RESUMO

Antecedentes: Entre pacientes com acidente vascular cerebral isquêmico (AVCI) agudo com divergência entre gravidade do déficit e volume do infarto, a trombectomia em 6 a 24 horas tem eficácia e segurança semelhantes ao tratamento em até 6 horas. Entretanto, a viabilidade da imagem ponderada em T2 com difusão (DWI) da ressonância magnética necessita validação. Objetivo: Investigar o prognóstico de pacientes com AVCI que recebem tratamento endovascular (EVT) em até 6 horas e de 6-24 horas usando tomografia computadorizada sem contraste (NCCT) e DWI. Métodos: Duzentos e nove pacientes com AVCI de circulação anterior submetidos a EVT foram divididos em ≤ 6 horas e 6-24 horas. Pacientes com sintomas até 6 horas foram tratados se NIHSS ≥ 7 e ASPECTS ≥ 5; aqueles com AVCI ao despertar (WUS) ou com sintomas entre 6-24 horas da última vez em que foram vistos bem (WUS/AVC de fase tardia, LPS) foram tratados se NIHSS ≥ 7 e ASPECTS ≥ 5. Resultados: As porcentagens de pacientes submetidos a implante de stent intracraniano e angioplastia intracraniana sem stent diferiram entre os dois grupos (p <0,001). As taxas de recanalização 0, 1, 2a e 2b não diferiram entre 6 horas e 6-24 horas (p> 0,05). A taxa de recanalização de grau 3 no grupo 6 horas foi menor do que 6-24 horas (p = 0,043). Pontuação na Escala Rankin (3 meses) não foi diferente (p = 0,629). Conclusões: EVT é um tratamento seguro e eficaz para pacientes com WUS e LPS selecionados por meio de imagens baseadas em NCCT e DWI.

Keywords:

Endovascular Treatment - Non-contrast Computed Tomography - Diffusion Magnetic Resonance Imaging - Stroke

Palavras-chave:

Tratamento Endovascular - Tomografia Computadorizada sem Contraste - Ressonância Magnética com Imagem Ponderada - Acidente Vascular Cerebral

• References

• 1 Menon BK, Sajobi TT, Zhang Y, Rempel JL, Shuaib A, Thornton J, et al. Analysis of workflow and time to treatment on thrombectomy outcome in the ESCAPE randomized controlled trial. Circulation. 2016 Jun 7;133(23):2279-86. https://doi.org/10.1161/CIRCULATIONAHA.115.019983
• 2 Desai SM, Rocha M, Molyneaux BJ, Starr M, Kenmuir CL, Gross BA, et al. Thrombectomy 6-24 hours after stroke in trial ineligible patients. J Neurointerv Surg. 2018 Nov;10(11):1033-7. https://doi.org/10.1136/neurintsurg-2018-013915
• 3 Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. https://doi.org/10.1056/NEJMoa1411587
• 4 Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018 Jan 4;378(1):11-21. https://doi.org/10.1056/NEJMoa1706442
• 5 Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018 Feb 22;378(8):708-18. https://doi.org/10.1056/NEJMoa1713973
• 6 Ducroux C, Khoury N, Lecler A, Blanc R, Chetrit A, Redjem H, et al. Application of the DAWN clinical imaging mismatch and DEFUSE 3 selection criteria: benefit seems similar but restrictive volume cut-offs might omit potential responders. Eur J Neurol. 2018 Aug;25(8):1093-9. https://doi.org/10.1111/ene.13660
• 7 Bracard S, Ducrocq X, Mas JL, Soundant M, Oppenheim C, Moulin T, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016 Oct 1;15(11):1138-47. https://doi.org/10.1016/S1474-4422(16)30177-6
• 8 Desai SM, Haussen DC, Aghaebrahim A, Al-Bayati AR, Santos R, Nogueira RG, et al. Thrombectomy 24 hours after stroke: beyond DAWN. J Neurointerv Surg. 2018 Nov;10(11):1039-42. https://doi.org/10.1136/neurintsurg-2018-013923
• 9 Schröder J, Thomalla G. A critical review of Alberta stroke program early CT score for evaluation of acute stroke imaging. Front Neurol. 2017 Jan 12;7:245. https://doi.org/10.3389/fneur.2016.00245
• 10 Wolman DN, Iv M, Wintermark M, Zaharchuk G, Marks MP, Do HM, et al. Can diffusion- and perfusion-weighted imaging alone accurately triage anterior circulation acute ischemic stroke patients to endovascular therapy? J Neurointerv Surg. 2018 Dec;10(12):1132-6. https://doi.org/10.1136/neurintsurg-2018-013784
• 11 González RG, Copen WA, Schaefer PW, Lev MH, Pomerantz SR, Rapalino O, et al. The Massachusetts General Hospital acute stroke imaging algorithm: an experience and evidence based approach. J Neurointerv Surg. 2013 Apr 8;5(1 Suppl 1):i7-12. https://doi.org/10.1136/neurintsurg-2013-010715
• 12 Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, 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 Mar;49:e46-110. https://doi.org/10.1161/STR.20200317202003170158
• 13 Leslie-Mazwi TM, Hirsch JA, Falcone GJ, Schaefer PW, Lev MH, Rabinov JD, et al. Endovascular stroke treatment outcomes after patient selection based on magnetic resonance imaging and clinical criteria. JAMA Neurol. 2016 Jan;73(1):43-9. https://doi.org/10.1001/jamaneurol.2015.3000
• 14 Konstas AA, Minaeian A, Ross IB. Mechanical thrombectomy in wake-up strokes: a case series using Alberta Stroke Program Early CT Score (ASPECTS) for patient selection. J Stroke Cerebrovasc Dis. 2017 Jul 1;26(7):P1609-14. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.02.024
• 15 Santos T, Carvalho A, Cunha AA, Rodrigues M, Gregório T, Paredes L, et al. NCCT and CTA-based imaging protocol for endovascular treatment selection in late presenting or wake-up strokes. J Neurointerv Surg. 2019 Feb;11(2):200-3. https://doi.org/10.1136/neurintsurg-2018-014051
• 16 Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weighted MR imaging of the brain. Radiology. 2000 Nov;217(2):331-45. https://doi.org/10.1148/radiology.217.2.r00nv24331
• 17 Albers GW, Goyal M, Jahan R, Bonafe A, Diener H-C, Levy EI, et al. Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME. Ann Neurol. 2016 Jan;79(1):76-89. https://doi.org/10.1002/ana.24543
• 18 Hand PJ, Wardlaw JM, Rivers CS, Armitage PA, Bastin ME, Lindley RI, et al. MR diffusion-weighted imaging and outcome prediction after ischemic stroke. Neurology. 2006 Apr 25;66(8):1159-63. https://doi.org/10.1212/01.wnl.0000202524.43850.81
• 19 Han M, Choi JW, Rim N-J, Kim SY, Suh H-I, Lee KS, et al. Cerebral infarct volume measurements to improve patient selection for endovascular treatment. Medicine (Baltimore). 2016 Aug;95(35):e4702. https://doi.org/10.1097/MD.20200317202003174702
• 20 Longo M, Bernava G, Calamuneri A, Caragliano AA, Pitrone A, Papa R, et al. MRI patient selection for endovascular thrombectomy in acute ischemic stroke: correlation between pretreatment diffusion weighted imaging and outcome scores. Radiol Med. 2018 Aug;123(8):609-17. https://doi.org/10.1007/s11547-018-0887-2