My comments suggest these people are fucking incompetent!
Article Commentary: “Combining Early Ischemic Change and Collateral Extent for Functional Outcomes After Endovascular Therapy”
Improvements in endovascular therapy (EVT) have increased the rate of successful reperfusion(Survivors don't give a flying fuck about successful reperfusion, that is only the first step to 100% recovery! WHAT EXACTLY ARE YOUR FOLLOWON STEPS TO GET TO 100%?) in patients with acute ischemic stroke caused by large vessel occlusions. This, in turn, is associated with higher rates of functional independence(And somehow you blithering idiots don't understand survivors want 100% recovery, not just functional independence.
You'll want that recovery when you become the 1 in 4 per WHO that has a stroke!)
post-EVT in these patients. Despite this, predicting(I'd have everyone fired who works on predicting recovery rather than delivering recovery!) functional outcomes after EVT remains elusive. Previous studies have highlighted the strong prognostic value of computed tomography perfusion (CTP) or diffusion-weighted imaging evaluation of ischemic core volume (ICV) regardless of reperfusion status.1,2 Further, CTP defined large core has been shown to be a better predictor of poor outcome than the computed tomography (CT) based Alberta Stroke Program Early Computed Tomography Score (ASPECTS) alone.3 However, it may be beneficial to develop methods to leverage more routinely available imaging modalities such as CT and computed tomography angiography in predicting patient outcomes.
In this post hoc analysis, the authors examined the combined impact of early ischemic changes (EIC) and the extent of collateral circulation in influencing functional outcomes post-EVT. This was examined via utilization of ASPECTS and regional leptomeningeal contrast filling of collaterals, as defined by the multiphase CTA (mCTA) collateral extent to generate a 20-point score called the mCTA-ACE score. The authors aimed to find if the mCTA-ACE score was correlated with functional outcomes post-EVT and if the mCTA-ACE score and CTP-derived ICV were correlated in predicting functional outcomes.
They had an intention-to-treat population of 1577 patients with anterior AIS of whom 368 that had a mCTA and underwent EVT were included in their analysis. The median mCTA-ACE score was 17, and those with mCTA-ACE score >17 had lower baseline National Institutes of Health Stroke Scale, more distal occlusions and lower CTP-derived ICV. In multivariable analysis, the probability of mRS score ≤2, return to prestroke level of function and mRS score ≤1 increased for each 1-point increase in the mCTA-ACE score and the probability of mortality, and any PH decreased for each 1-point increase in the mCTA-ACE score. The authors also analyzed 173 patients who had assessable ICV and found there was an inverse correlation between mCTA-ACE score and ICV, with the mCTA-ACE score and ICV showing similar predictive value for estimating outcomes post-EVT. They showed that patients with minimal EIC and robust collateral circulation had significantly better functional outcomes than those with extensive EIC and poor collateral circulation at least at 90 days post-EVT, further emphasizing the utility of the mCTA- ACE score which combines these elements.
These results suggest that leveraging the mCTA-ACE score could potentially allow clinicians to stratify patients and improve the prediction of patient recovery(I'd have everyone fired who works on predicting recovery rather than delivering recovery!)even when unable to access CTP or other ICV measurements. This potentially expands providers’ ability to predict functional outcomes for patients, allowing for optimization of resource allocation and improving prognosis communication and expectation setting for patients and their families.
The study's findings are promising, but they also raise several questions and have some limitations. One potential issue is the need to standardize imaging protocols and provide further training for assessing EIC and collateral extent. This variation has been shown to depend on the imaging modality and radiologist expertise.4 The determination of return to prestroke level of function was obtained through standardized telephone interviews and is inherently subjective, which differs from prior studies that employ the modified Rankin Scale. Lastly, it is important to note that the findings may not be generalizable given the AcT trial took place exclusively in Canada, with all patients receiving thrombolysis (tenecteplase or alteplase), and this analysis derived from a small subset of those patients. Further studies in more diverse populations can aid in validating these results. Additionally, while we understand that "time is brain," the optimal time window for employing EVT in patients with different degrees of early ischemic changes and varying degrees of collateral circulation still needs to be determined. This warrants further investigation of the mechanisms by which collateral circulation influences ischemic injury.
This study demonstrates that integrating early ischemic changes and collateral extent, as assessed through the mCTA-ACE score, can offer an alternate approach to ICV in predicting functional outcomes post-EVT. While the findings are promising, they also highlight the need for further research to validate and expand upon these results.
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