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Early Anticipation of Candidacy for Intra-Arterial Reperfusion Therapy Based on Baseline Clinical Stroke Subtypes: Comparison with Multiparametric MRI Taken within 4.5 Hours from Stroke Onset

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      Abstract

      Background

      The decision to proceed with intra-arterial (IA) reperfusion therapy is typically made late in the course of in-hospital treatment for acute ischemic stroke. Early anticipation of candidacy for IA reperfusion therapy based on clinical stroke subtypes would be useful for guiding stroke management. The aim of this study was to investigate the relationship between the clinical Oxfordshire Community Stroke Project (OCSP) classification and MRI results taken within a 4.5-hour time window from stroke onset, with the hypothesis that the persistence of major arterial occlusion and extended ischemic penumbra, key criteria for proceeding with IA reperfusion therapy, would be distinctive between the clinical stroke subtypes.

      Methods

      A total of 161 patients with acute ischemic stroke in the anterior circulation were included in this study. All patients were treated with intravenous alteplase, and MRI scans were performed following alteplase initiation. Prior to treatment, the patients were categorized, based on the OCSP classification scheme, as having total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), or lacunar infarcts (LACI). The relationship between OCSP subtypes, MRI parameters, and clinical variables was analyzed.

      Results

      Overall, 40/161 patients (24.8%) were candidates for IA rescue reperfusion. With respect to the classification, 30/69 TACI (43.5%), 6/33 PACI (18.2%), and 4/59 LACI patients (6.8%) were candidates (p < 0.001). Major arterial occlusion was found in 56/161 patients (34.8%), and 46/69 TACI (66.7%), 6/33 PACI (18.2%), and 4/59 LACI patients (6.8%) had a major arterial occlusion (p < 0.001). A perfusion-diffusion mismatch greater than 20% was found in 85/161 patients (52.8%). More specifically, 40/69 TACI (58.0%), 25/33 PACI (75.8%), and 20/59 LACI patients (33.9%) had a perfusion-diffusion mismatch (p < 0.001). However, in terms of the total area of mismatch, 66.0% of patients with ASPECTS DWI-PWI ≥2 (Alberta Stroke Program Early CT Score) were classified as TACI patients (p < 0.001) and of the patients with ASPECTS DWI-PWI ≥3, 74.3% were classified as TACI patients (p < 0.001). Relative to candidates for IA rescue reperfusion, the clinical TACI group showed 75.0% sensitivity, 67.8% specificity, a positive predictive value of 43.5%, and a negative predictive value of 89.1%.

      Conclusions

      In this study, patients classified as having clinical TACI were significantly more likely to be candidates for IA rescue reperfusion. Additionally, they incurred a higher incidence of persistent major arterial occlusion and had a penumbra area that was significantly larger than normal. Therefore, clinical OCSP can be used as an ‘early warning system’ for IA reperfusion candidacy, which can allow for advanced preparation of IA therapy and theoretically shorten treatment time and reduce infarction.

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      Author and article information

      Affiliations
      aDepartments of Neurology, Kyungpook National University Hospital, Daegu, Republic of Korea
      bDepartments of Neuroradiology, Kyungpook National University Hospital, Daegu, Republic of Korea
      cDepartments of Cerebrovascular Center, Kyungpook National University Hospital, Daegu, Republic of Korea
      dSchool of Medicine, Kyungpook National University, Daegu, Republic of Korea
      Author notes
      *Assist. Prof. Yang-Ha Hwang, MD, Department of Neurology, Kyungpook National University Hospital, 130, Dongduk-ro, Jung-gu, Daegu 700-721 (Republic of Korea), E-Mail yangha.hwang@ 123456gmail.com
      Journal
      Cerebrovasc Dis Extra
      Cerebrovasc Dis Extra
      CEE
      Cerebrovascular Diseases Extra
      S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.ch )
      1664-5456
      1664-5456
      Jan-Dec 2013
      11 June 2013
      11 June 2013
      : 3
      : 1
      : 85-94
      23885261 3711001 10.1159/000353130 cee-0003-0085
      Copyright © 2013 by S. Karger AG, Basel
      Counts
      Figures: 2, Tables: 3, References: 24, Pages: 10
      Categories
      Original Paper

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