Discrepancy between post-treatment infarct volume and 90-day outcome in the ESCAPE randomized controlled trial

Author:

Ganesh Aravind1ORCID,Menon Bijoy K1234,Assis Zarina A12,Demchuk Andrew M124,Al-Ajlan Fahad S5,Al-Mekhlafi Mohammed A124,Rempel Jeremy L6,Shuaib Ashfaq7ORCID,Baxter Blaise W8,Devlin Thomas9,Thornton John10,Williams David11,Poppe Alexandre Y12ORCID,Roy Daniel13,Krings Timo14,Casaubon Leanne K15,Kashani Nima12,Hill Michael D1234ORCID,Goyal Mayank124

Affiliation:

1. Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada

2. Department of Radiology, University of Calgary, Calgary, Canada

3. Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Canada

4. Hotchkiss Brain Institute, Calgary, Canada

5. Department of Neurosciences, King Faisal Specialist Hospital, Riyadh, Saudi Arabia

6. Department of Radiology, University of Alberta, Edmonton, Canada

7. Stroke Program and Department of Medicine, University of Alberta, Edmonton, Canada

8. Department of Radiology, University of Tennessee, Erlanger Hospital, Knoxville, TN, USA

9. Department of Neurology, University of Tennessee, Erlanger Hospital, Knoxville, TN, USA

10. Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland

11. Department of Geriatric & Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland

12. Department of Neurosciences, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Canada

13. Department of Radiology, CHUM, Université de Montréal, Montreal, Canada

14. Department of Medical Imaging, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Canada

15. Division of Neurology, Stroke Program, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Canada

Abstract

Background Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better. Aims We explored factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome. Methods We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24–48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24–48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between “discrepant cases” – those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV – and “non-discrepant cases”. Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome. Results Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement ( p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age ( p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS ( p = 0.007) and post-stroke complications ( p = 0.026). Absence of vascular risk-factors ( p = 0.004), CT-based lentiform nucleus sparing ( p = 0.002), lower 24-hour NIHSS ( p = 0.001), and absence of complications ( p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results. Conclusions Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01778335 .

Publisher

SAGE Publications

Subject

Neurology

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