Thrombectomy Tied to Better Outcomes in Large Core Strokes, Too

Once again failure to even measure how badly the neuronal cascade of death is after these large strokes. Endpoints of stroke research are missing a lot, researchers don't know what they should be doing. With a defined stroke strategy, everyone in the world would be going to the same endpoint. 100% survivor recovery.
http://www.medpagetoday.com/Cardiology/PCI/61282?xid=nl_mpt_DHE_2016-11-08&eun=g424561d0r&pos=1
Stroke patients with large swaths of irreversibly-injured tissue at risk for significant infarct expansion still benefited from endovascular therapy, a single-center study found.
Among individuals with large baseline ischemic cores and mismatch profiles, endovascular therapy was associated with:

• A favorable shift in the overall distribution of 90-day modified Rankin Scale (mRS) scores (OR 2.56, 95% CI 2.50-8.47)
• Higher rates of functional independence (mRS scores 0-2; 25% versus 0%, P=0.04)
• Smaller final infarct volumes (average 87 versus 242 mL, P<0.001)

By 90 days, type 2 parenchymal hematomas occurred at similar rates between control and treatment groups (4% versus 7%, P>0.99), according to Raul G. Nogueira, MD, of Grady Memorial Hospital in Atlanta, and colleagues in their study published online in JAMA Neurology. Also comparable for the two groups, respectively, were risk of hemicraniectomy (7% versus 21%, P=0.10) and mortality (29% versus 48%, P=0.75).
"In properly selected patients, endovascular therapy appears to benefit patients with large core and large mismatch profiles," the investigators concluded.
"Somehow, these patients with malignant profiles did not experience worse outcomes than expected, and they actually benefited from the right therapy, for the right patient, at the right time," agreed David S. Liebeskind, MD, of University of California, Los Angeles, writing in an accompanying editorial.
"The categorical exclusion of large ischemic cores may have been warranted in prior trials to establish the role of endovascular therapy, yet uncertainties or shades of gray abound in the daily triage of patients with such lesions."
"[The authors] challenge the historical tenet of imaging selection that eliminates the only therapeutic opportunity for patients with large ischemic cores and large mismatch imaging profiles to avoid devastating outcomes. Their article builds on mounting data from a variety of approaches with CT and MRI that question the way we use imaging and the process of how we consider optimal therapeutic strategies for patients with stroke," Liebeskind added.
"The results of this study, in combination with other recent reports using different imaging definitions of large infarcts, suggest that individual stroke outcomes and novel opportunities to expand therapeutic benefits of endovascular thrombectomy are undeniably multivariable and informed by multidimensional imaging," he wrote.
Nogueira's group analyzed data retrieved from stroke patients with proximal occlusion on CT angiography and baseline ischemic cores more than 50 mL on CT perfusion imaging (n=56) who got endovascular therapy or medical therapy alone at a tertiary care center from 2011 to 2015. The case-control design matched patients based on age, baseline ischemic core volume on CT perfusion imaging, and glucose levels.
A sensitivity analysis showed that patients with a baseline ischemic core more than 70 mL had a substantial reduction in final infarct volumes (mean 110 versus 319 mL, P<0.001) but no statistically significant improvement in the distribution of mRS scores (P=0.18).

Nogueira reported receiving research support fom Stryker Neurovascular, Covidien, and Penumbra.
Liebeskind reported working as a consultant to Stryker and Medtronic and is employed by the University of California, which holds a patent on retriever devices for stroke.

• Primary Source

  JAMA Neurology

  Source Reference: Rebello LC, et al "Endovascular treatment for patients with acute stroke who have a large ischemic core and large mismatch imaging profile" JAMA Neurol 2016; DOI: 10.1001/jamaneurol.2016.3954