Relationships Between Imaging Assessments and Outcomes in Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke
In this prespecified analysis of the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial, Albers et al assessed the relationship between baseline and 27-hour follow-up imaging assessments with clinical outcomes.
More than 90% reperfusion was considered successful reperfusion. On the basis of perfusion imaging on presentation, we classified patients were as having either target mismatch or no–target mismatch profile. Perfusion imaging was mandatory only in the initial phase of the study, and the protocol was modified to make it optional after 71 patients were enrolled; however, the majority of patients continued to have perfusion imaging before randomization. The study was terminated prematurely because the efficacy end point was met in the first planned interim analysis, and therefore many of the prespecified subgroup analyses were underpowered, especially within the no–target mismatch patient group. The salient findings of this analysis were as follows:
Twenty-seven–hour infarct volume and successful reperfusion both independently predict favorable outcome, irrespective of treatment allocation.
Within the target mismatch group, endovascular intervention was associated with significantly higher rates of successful reperfusion and functional independence, as well as significantly lower 27-hour infarct volume.
Baseline ischemic core and perfusion lesion volumes and Alberta Stroke Program Early CT Scan (ASPECTS) score were not significantly predictive of clinical outcome.
The single most important finding was that successful reperfusion status is an independent predictor of favorable outcome, even when adjusting for final (27 hours) infarct volume. The finding that baseline ischemic core is not associated with clinical outcome differs from other, similar studies and likely reflects the trial population generated on the basis of specific selection criteria. See p 2786.
Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting: Systematic Review and Meta-Analysis
Carotid artery stenting (CAS) has emerged as an alternative option to carotid endarterectomy (CEA) for patients with carotid artery stenosis. Data from randomized control trials have suggested a poorly understood excess of periprocedural stroke after CAS and myocardial infarction (MI) excess after CEA; this differential effect has led to comparable net clinical effect of the 2 procedures, but the key question of procedure-specific MI risk and relation to specific risk factors remain unanswered.
In this systematic review and meta-analysis, Boulanger et al investigated the risk of periprocedural MI and death after CEA and CAS, as well as the effect of 9 specific risk factors on MI and death for each procedure type.
The investigators found no significant difference in absolute rates of 30-day MI in CEA versus CAS (0.87% versus 0.70%). Notably, the CEA-related MI rate reported is ≈50% when compared with the point estimate from pooled analyses from large randomized control trials. Similarly, no significant difference was found in 30-day mortality, (0.92% versus 1.03%). Stroke accounted for a significantly higher percentage of periprocedural death than MI.
Of the 9 risk factors assessed, only sex had a significantly differential effect on periprocedural MI between CAS and CEA, with men having a significantly lower risk of MI than women in CAS (P=0.01). It should be emphasized that this should not weigh in the decision of CAS versus CEA decision, given that (1) the analysis was not adjusted for other risk factors and (2) the sex effect in CEA was neutral and not in favor of women. Certain individual risk factors were significantly associated with CEA periprocedural mortality and not with CAS mortality, but the trends were in the same direction, and mostly reflected a significantly higher power and thus more narrow confidence intervals in CEA studies. See p 2843.
Maximal Admission Core Lesion Compatible With Favorable Outcome in Patients With Stroke Undergoing Endovascular Procedures
Ischemic core volume on presentation has been identified as a potent predictor of long-term functional outcome. However, a specific numeric predictive cutoff value has not be identified. In this retrospective analysis, Ribo et al sought to define the maximal admission lesion volume compatible with favorable outcome (MALCOM), which was defined as the admission core volume above which the possibility of favorable outcome (modified Rankin Scale score, 0–2) was <10%, in patients with internal carotid artery and middle cerebral artery occlusion undergoing endovascular intervention.
MALCOM was found to be 39 mL; 72% of patients had a baseline core lesion less than MALCOM. Despite recanalization, only 12% of patients with core lesion greater than MALCOM achieved a favorable outcome as opposed to 64% of those with core lesion less than MALCOM (P=0.01). In a logistic regression analysis, MALCOM was found to be potent, independent predictor of favorable outcome (odds ratio, 9.3; P=0.01), independent of recanalization status or age.
Study limitations should be taken into account when interpreting the findings: patients were chosen based on ASPECTS score of >6, therefore, excluding subjects with potentially large ischemic core infarcts. Lesion topology was not taken into account. Computed tomographic perfusion and magnetic resonance imaging yielded different MALCOM thresholds, and finally, octogenarians had a significantly lower MALCOM than younger patients (15 versus 40 mL). In summary, MALCOM presents an interesting patient selection tool for possible endovascular intervention, but further refinement and validation are necessary. See p 2849.
- © 2015 American Heart Association, Inc.
- Relationships Between Imaging Assessments and Outcomes in Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke
- Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting: Systematic Review and Meta-Analysis
- Maximal Admission Core Lesion Compatible With Favorable Outcome in Patients With Stroke Undergoing Endovascular Procedures
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