Large Volumes of Critically Hypoperfused Penumbral Tissue Do Not Preclude Good Outcomes After Complete Endovascular Reperfusion

So you are screwed if you don't fit the inclusion criteria. A great stroke association would leave no survivor behind. We would solve stroke problems for everyone, not just the easy ones.
http://stroke.ahajournals.org/content/47/1/94.abstract?sid=a1b8f447-dbba-4e5d-bcff-f1b5a4849a56

Redefining Malignant Profile

1. Raul G. Nogueira, MD*;
2. Diogo C. Haussen, MD*;
3. Seena Dehkharghani, MD;
4. Leticia C. Rebello, MD;
5. Andrey Lima, MD;
6. Meredith Bowen, BA;
7. Samir Belagaje, MD;
8. Aaron Anderson, MD;
9. Michael Frankel, MD

+ Author Affiliations

1. From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA.

1. Correspondence to Raul G. Nogueira, MD, 49 Jesse Hill Jr Dr SE, Room #333, Atlanta, GA 30303. E-mail raul.g.nogueira@emory.edu

1. ↵* Drs Nogueira and Haussen contributed equally and qualify for equal level of authorship.

Abstract

Background and Purpose—Acute ischemic stroke patients with large volumes of severe hypoperfusion (T_max>10 s>100 mL) on magnetic resonance imaging have a higher likelihood of intracranial hemorrhage and poor outcomes after reperfusion. We aim to evaluate the impact of the extent of T_max>10 s CTP lesions in patients undergoing successful treatment.

Methods—Retrospective database review of endovascular acute ischemic stroke treatment between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline RAPID CTP and full reperfusion (mTICI 3). The primary outcome was the impact of the T_max>10 s lesion spectrum on infarct growth. Secondary safety and efficacy outcomes included parenchymal hematomas and good clinical outcomes (90-day modified Rankin Scale score, 0–2).

Results—Of 684 treated patients, 113 patients fit the inclusion criteria. T_max>10 s>100 mL patients (n=37) had significantly higher baseline National Institutes of Health Stroke Scale (20.7±3.8 versus 17.0±5.9; P<0.01), more internal carotid artery terminus occlusions (29% versus 9%; P=0.02), and larger baseline (38.6±29.6 versus 11.7±15.8 mL; P<0.01) and final (60.7±60.0 versus 29.4±33.9 mL; P<0.01) infarct volumes when compared with patients without T_max>10 s>100 mL (n=76); however, the 2 groups were otherwise well balanced. There were no significant differences in infarct growth (22.1±51.6 versus 17.8±32.4 mL; P=0.78), severe intracranial hemorrhage (PH2: 2% versus 4%; P=0.73), good outcomes (90-day mRS score, 0–2: 56% versus 59%; P=0.83), or 90-day mortality (16% versus 7%; P=0.28). On multivariate analysis, only baseline National Institutes of Health Stroke Scale (odds ratio, 1.19; 95% confidence interval, 1.06–1.34; P<0.01) and baseline infarct core volume (odds ratio, 1.05; 95% confidence interval, 1.02–1.08; P<0.01) were independently associated with T_max>10 s>100 mL. There was no association between T_max>10 s>100 mL with any PH, good outcome, or infarct growth.

Conclusions—In the setting of limited baseline ischemic cores, large T_max>10 s lesions on computed tomographic perfusion do not seem to be associated with a higher risk of parenchymal hematomas and do not preclude good outcomes in patients undergoing endovascular reperfusion with contemporary technology.