MRI-Based Screening Improves Assignment of Patients With Stroke to Endovascular Treatment

So instead of increasing the pool of stroke patients being treated we are subjected to  lucky candidates with lesser damage being treated better.  That is not the correct goal. Our stroke associations should have the goal of 100% recovery for all. Not just the lucky ones.
http://dgnews.docguide.com/mri-based-screening-improves-assignment-patients-stroke-endovascular-treatment?
A system developed for determining which patients with severe strokes are most likely to benefit from catheter-based systems for blood clot removal can lead to a greater percentage of screened patients receiving treatment and to outcomes similar to recent studies that found significant treatment benefits.
In a study published online by JAMA Neurology, researchers report how the precision of their classification system, which combines diffusion magnetic resonance imaging (MRI) with key clinical characteristics, more than doubled the percentage of screened patients who were assigned to and probably benefited from treatment.
“Endovascular therapy has been proven to be effective and superior to other approaches for the treatment of severe strokes caused by the blockage of large brain arteries,” said senior author Gilberto González, MD, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts. “The critical question has been how to optimise its use to benefit the most patients while minimising any harm. It appears [our] approach to patient selection is superior to other approaches and may be the optimal approach.”
“Our work shows that MRI identifies patients with greater precision, which means that fewer patients are inaccurately excluded from a treatment that might otherwise benefit them,” said lead author Thabele Leslie-Mazwi, MD, Massachusetts General Hospital. “As endovascular therapy expands at a regional, national and international level, we think this precision will be essential to providing the most personalised and cost-effective care.”
The past year has seen an almost complete turnaround for endovascular treatment, with major clinical trials in several countries reporting that use of the most sophisticated clot-removing devices -- often in combination with tissue plasminogen activator (tPA) -- led to significant recovery in 33% to 70% of patients with major stokes if treatment was initiated within 6 hours of symptom onset. The studies achieving the best outcomes used several advanced computed tomography (CT)-based imaging techniques for patient selection. In contrast, the researchers at Mass Gen primarily used diffusion-weighted MRI because it produces the most precise estimate of the size of the ischemic core.
The researchers analysed treatment results for all patients receiving endovascular therapy at Mass Gen from 2012 through 2014 for acute strokes caused by blockage of 1 of 2 major arteries within the brain, along with a subset of patients who did not receive endovascular treatment because it was determined to have little or no potential benefit for them.
The research team had previously developed a system for classifying patients as likely, uncertain or unlikely to benefit from treatment based on their age, time from symptom onset, size of the clot and the blocked artery, other health issues, and the size of the ischemic core, as determined by MRI. The current study also included a group of patients who received endovascular treatment after CT scanning only, either because they were unable to receive MRI or for other reasons.
Among 103 patients who received endovascular therapy during the study period, 72 were screened with diffusion MRI, leading to 40 being classified as likely to benefit and 32 for whom benefit was uncertain. Three months after treatment, 52% of the likely-to-benefit group had a favourable outcome, defined as a return to complete functional independence, a result achieved by 32% of the uncertain-to-benefit group and 31% of those evaluated by CT only.
Results were even better in the likely-to-benefit patients for whom treatment restored circulation to tissue around the ischemic core, with favourable outcomes in 74%. None of the patients classified as unlikely to benefit had favourable outcomes.
“The next frontier to investigate is treatment 6 to 24 hours after stroke onset,” said co-author Joshua Hirsch, MD, Massachusetts General Hospital. “Data we have accumulated over the past decade suggests that many patients may be successfully treated at this late stage, and MRI is the most powerful means to accurately identify these individuals. If that is true, there may be time to transfer patients who first present at regional hospitals to centres like the Mass Gen that have the capability to conduct this type of screening program. While diffusion MRI is broadly available, only a few major institutions have recognised its critical role and made it available around the clock in emergent fashion for the evaluation of severe stroke patients.”
SOURCE: Massachusetts General Hospital