Persistent Target Mismatch Profile >24 Hours After Stroke Onset in DEFUSE 3

• Published in: Stroke (1970) Vol. 50; no. 3; pp. 754 - 757
• Main Authors: Christensen, Søren, Mlynash, Michael, Kemp, Stephanie, Yennu, Amarnath, Heit, Jeremy J, Marks, Michael P, Lansberg, Maarten G, Albers, Gregory W
• Format: Journal Article
• Language: English
• Published: United States American Heart Association, Inc 01.03.2019
• Subjects: Aged; Aged, 80 and over; Brain Ischemia - diagnostic imaging; Brain Ischemia - surgery; Carotid Stenosis - diagnostic imaging; Carotid Stenosis - surgery; Diffusion Magnetic Resonance Imaging; Endovascular Procedures - methods; Female; Humans; Infarction, Middle Cerebral Artery - diagnostic imaging; Infarction, Middle Cerebral Artery - surgery; Male; Middle Aged; Perfusion Imaging; Stroke - diagnostic imaging; Stroke - surgery; Thrombectomy; Tomography, X-Ray Computed; Treatment Outcome; Triage; magnetic resonance imaging; reperfusion; stroke; thrombectomy
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/STROKEAHA.118.023392

BACKGROUND AND PURPOSE—Efficacy of endovascular thrombectomy has been demonstrated up to 24 hours after stroke onset in patients selected with perfusion imaging. We hypothesized that a persistent favorable perfusion profile exists in some patients beyond 24 hours from the onset and can be predicted by a lower baseline hypoperfusion intensity ratio, which indicates favorable collaterals. METHODS—We identified control arm patients from the DEFUSE 3 trial (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) with a diffusion weighted imaging and perfusion magnetic resonance imaging performed 24 hours following randomization and compared imaging and clinical variables between patients with persistent mismatch versus patients who no longer had a mismatch 24 hours after randomization. RESULTS—Eighteen percent of the control arm patients had a persistent favorable profile >38 hours after last known well time. These patients had similar baseline diffusion weighted imaging and Tmax >6 seconds volumes as patients whose initially favorable perfusion profile became unfavorable (diffusion weighted imaging lesion 7 versus 17 mL; P=0.17, Tmax >6 seconds 98 versus 100 mL; P=0.48) yet experienced less infarct growth (15 versus 59 mL; P<0.001) and had 3-fold smaller infarct volumes (15 versus 59 mL; P<0.001) 24 hours after randomization. Patients with a persistent favorable perfusion profile had a significantly lower hypoperfusion intensity ratio on baseline imaging (0.2 versus 0.4; P<0.01). Favorable clinical outcome at 90 days occurred in only 10% of the persistent mismatch patients. CONCLUSIONS—About 20% of patients with a middle cerebral artery or internal carotid artery occlusion who present in an extended time window and are not treated with thrombectomy have a persistent mismatch for at least an additional 24 hours. These patients have a favorable hypoperfusion intensity ratio at presentation, may experience delayed infarct expansion, and have poor clinical outcomes. Clinical trials are needed to determine if patients with a favorable perfusion profile benefit from reperfusion beyond 24 hours. CLINICAL TRIAL REGISTRATION—URLhttps://www.clinicaltrials.gov. Unique identifierNCT02586415.