Journal article
Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data
Lancet neurology, Vol.18(1), pp.46-55
01/2019
DOI: 10.1016/S1474-4422(18)30314-4
PMID: 30413385
Abstract
CT perfusion (CTP) and diffusion or perfusion MRI might assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of irreversibly injured ischaemic core and potentially salvageable penumbra volumes were associated with functional outcome and whether they interacted with the treatment effect of endovascular thrombectomy on functional outcome.
In this systematic review and meta-analysis, the HERMES collaboration pooled patient-level data from all randomised controlled trials that compared endovascular thrombectomy (predominantly using stent retrievers) with standard medical therapy in patients with anterior circulation ischaemic stroke, published in PubMed from Jan 1, 2010, to May 31, 2017. The primary endpoint was functional outcome, assessed by the modified Rankin Scale (mRS) at 90 days after stroke. Ischaemic core was estimated, before treatment with either endovascular thrombectomy or standard medical therapy, by CTP as relative cerebral blood flow less than 30% of normal brain blood flow or by MRI as an apparent diffusion coefficient less than 620 μm
/s. Critically hypoperfused tissue was estimated as the volume of tissue with a CTP time to maximum longer than 6 s. Mismatch volume (ie, the estimated penumbral volume) was calculated as critically hypoperfused tissue volume minus ischaemic core volume. The association of ischaemic core and penumbral volumes with 90-day mRS score was analysed with multivariable logistic regression (functional independence, defined as mRS score 0-2) and ordinal logistic regression (functional improvement by at least one mRS category) in all patients and in a subset of those with more than 50% endovascular reperfusion, adjusted for baseline prognostic variables. The meta-analysis was prospectively designed by the HERMES executive committee, but not registered.
We identified seven studies with 1764 patients, all of which were included in the meta-analysis. CTP was available and assessable for 591 (34%) patients and diffusion MRI for 309 (18%) patients. Functional independence was worse in patients who had CTP versus those who had diffusion MRI, after adjustment for ischaemic core volume (odds ratio [OR] 0·47 [95% CI 0·30-0·72], p=0·0007), so the imaging modalities were not pooled. Increasing ischaemic core volume was associated with reduced likelihood of functional independence (CTP OR 0·77 [0·69-0·86] per 10 mL, p
=0·29; diffusion MRI OR 0·87 [0·81-0·94] per 10 mL, p
=0·94). Mismatch volume, examined only in the CTP group because of the small numbers of patients who had perfusion MRI, was not associated with either functional independence or functional improvement. In patients with CTP with more than 50% endovascular reperfusion (n=186), age, ischaemic core volume, and imaging-to-reperfusion time were independently associated with functional improvement. Risk of bias between studies was generally low.
Estimated ischaemic core volume was independently associated with functional independence and functional improvement but did not modify the treatment benefit of endovascular thrombectomy over standard medical therapy for improved functional outcome. Combining ischaemic core volume with age and expected imaging-to-reperfusion time will improve assessment of prognosis and might inform endovascular thrombectomy treatment decisions.
Medtronic.
Details
- Title: Subtitle
- Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data
- Creators
- Bruce C V Campbell - Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia. Electronic address: bruce.campbell@mh.org.auCharles B L M Majoie - Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, NetherlandsGregory W Albers - Stanford Stroke Center, Stanford University, Stanford, CA, USABijoy K Menon - Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, CanadaNawaf Yassi - Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, AustraliaGagan Sharma - Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, AustraliaWim H van Zwam - Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute (CARIM), Maastricht, NetherlandsRobert J van Oostenbrugge - Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute (CARIM), Maastricht, NetherlandsAndrew M Demchuk - Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, CanadaFrancis Guillemin - Clinical Investigation Centre-Clinical Epidemiology, INSERM 1433, University of Lorraine and University Hospital of Nancy, Nancy, FrancePhilip White - Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UKAntoni Dávalos - Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, SpainAad van der Lugt - Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, NetherlandsKenneth S Butcher - Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, CanadaAboubaker Cherifi - Clinical Investigation Centre-Innovative Technology, INSERM 1433, University of Lorraine and University Hospital of Nancy, Nancy, FranceHenk A Marquering - Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, NetherlandsGeoffrey Cloud - Stroke Unit, Alfred Hospital and Monash University, Melbourne, VIC, AustraliaJuan M Macho Fernández - Department of Radiology, Hospital Clínic, Barcelona, SpainJeremy Madigan - Department of Neuroradiology, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UKCatherine Oppenheim - Department of Neuroradiology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, FranceGeoffrey A Donnan - The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, AustraliaYvo B W E M Roos - Department of Neurology, Academic Medical Center, Amsterdam, NetherlandsJai Shankar - Department of Radiology, QEII Health Science Center, Dalhousie University, Halifax, NS, CanadaHester Lingsma - Department of Public Health, Erasmus MC University Medical Center, Rotterdam, NetherlandsAlain Bonafé - Department of Neuroradiology, Hôpital Gui-de Chauliac, Montpellier, FranceHélène Raoult - Department of Neuroradiology, CHU Pontchaillou, Rennes, FranceMaría Hernández-Pérez - Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, SpainAditya Bharatha - Division of Diagnostic and Interventional Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, ON, CanadaReza Jahan - Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, CA, USAOlav Jansen - Department of Radiology and Neuroradiology, Universitätsklinikum Kiel, Kiel, GermanySébastien Richard - Department of Neurology, Stroke Unit, CIC-1433, INSERM U1116, University Hospital of Nancy, Nancy, FranceElad I Levy - Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USAOlvert A Berkhemer - Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, Netherlands; Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute (CARIM), Maastricht, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, NetherlandsMarc Soudant - Clinical Investigation Centre-Clinical Epidemiology, INSERM 1433, University of Lorraine and University Hospital of Nancy, Nancy, FranceLucia Aja - Department of Neurology, Hospital de Bellvitge, Barcelona, SpainStephen M Davis - Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, AustraliaTimo Krings - Department of Radiology, Toronto Western Hospital and University Health Network, University of Toronto, Toronto, ON, CanadaMarie Tisserand - Department of Neuroradiology, Foch Hospital, Suresnes, FranceLuis San Román - Stroke Unit, Alfred Hospital and Monash University, Melbourne, VIC, AustraliaAlejandro Tomasello - Radiology Department, Hospital Vall d'Hebron, Barcelona, SpainDebbie Beumer - Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute (CARIM), Maastricht, NetherlandsScott Brown - Altair Biostatistics, St Louis Park, MN, USADavid S Liebeskind - Neurovascular Imaging Research Core, Department of Neurology, University of California Los Angeles, Los Angeles, CA, USASerge Bracard - Department of Diagnostic and Interventional Neuroradiology, INSERM U 947, University of Lorraine and University Hospital of Nancy, Nancy, FranceKeith W Muir - Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UKDiederik W J Dippel - Department of Neurology, Erasmus MC University Medical Center, Rotterdam, NetherlandsMayank Goyal - Department of Radiology, University of Calgary, Foothills Hospital, Calgary, AB, CanadaJeffrey L Saver - Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USATudor G Jovin - Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USAMichael D Hill - Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, CanadaPeter J Mitchell - Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, AustraliaHERMES collaborators
- Contributors
- Colin P Derdeyn (Contributor) - University of Iowa, Radiology
- Resource Type
- Journal article
- Publication Details
- Lancet neurology, Vol.18(1), pp.46-55
- Publisher
- England
- DOI
- 10.1016/S1474-4422(18)30314-4
- PMID
- 30413385
- ISSN
- 1474-4422
- eISSN
- 1474-4465
- Grant note
- HTA/14/08/47 / Department of Health
- Language
- English
- Date published
- 01/2019
- Academic Unit
- Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984070412402771
Metrics
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