Comparing the outcomes on computed tomography (CT) perfusion of patients with large baseline ischaemic cores undergoing endovascular therapy with the outcomes of matched controls who had medical care alone, Leticia C Rebello and colleagues from the Grady Memorial Hospital, Emory University School of Medicine, Atlanta, USA, found that, in properly selected patients, endovascular therapy appears to benefit patients with large core and large mismatch profiles.
The investigators embarked on this study, published in JAMA Neurology, as endovascular therapy is typically not considered for patients with large baseline ischaemic cores, they sought to explore whether a subset of patients with large ischaemic cores, identified by CT perfusion imaging, who remain at risk for significant infarct expansion could still benefit from reperfusion to reduce their degree of disability.
They conducted a matched case-control study of patients with proximal occlusion after stroke (intracranial internal carotid artery and/or middle cerebral artery M1 and/or M2) on computed tomographic angiography and baseline ischaemic core greater than 50mL on CT perfusion at a tertiary care centre from 1 May, 2011, through 31 October, 2015. Patients receiving endovascular therapy and controls receiving medical treatment alone were matched for age, baseline ischaemic core volume on CT perfusion, and glucose levels. Baseline characteristics and outcomes were compared.
The primary outcome measure was the shift in the degree of disability among the treatment and control groups as measured by the modified Rankin Scale (mRS) at 90 days.
Rebello et al report on 56 patients who were matched across two equally distributed groups (mean [SD] age, 62.25 [13.92] years for cases and 58.32 [14.79] years for controls; male, 13 cases [46%] and 14 controls [50%]).
“Endovascular therapy was significantly associated with a favourable shift in the overall distribution of 90-day mRS scores (odds ratio, 2.56; 95% CI, 2.50–8.47; p=.04), higher rates of independent outcomes (90-day mRS scores of 0–2, 25% vs 0%; p=.04), and smaller final infarct volumes (mean [SD], 87  vs 242  mL; p<.001). One control (4%) and two treatment patients (7%) developed a parenchymal hematoma type 2 (p>.99). The rates of hemicraniectomy (2 [7%] vs 6 [21%]; p=.10) and 90-day mortality (7 [29%] vs 11 [48%]; p=.75) were numerically lower in the intervention arm. Sensitivity analysis for patients with a baseline ischaemic core greater than 70mL (12 pairs) revealed a significant reduction in final infarct volumes (mean [SD], 110  vs 319  mL; p<.001) but only a nonsignificant improvement in the overall distribution of mRS scores favouring the treatment group (p=.18). All 11 patients older than 75 years had poor outcomes (mRS score >3) at 90 days,” the authors write.
While this study shows the potential benefit of endovascular therapy in properly selected patients with large core and large mismatch profiles, Rebello et al maintain that future prospective studies are warranted.