Alwakaa Omar, Abo Kasem Rahim, Ramirez-Velandia Felipe, Wadhwa Aryan, Han Kimberly, Levitt Michael R, Alaraj Ali, Jabbour Pascal, Kim Joon-Tae, Howard Brian, Alawieh Ali, Wolfe Stacey Quintero, Starke Robert M, Psychogios Marios-Nikos, Shaban Amir, Goyal Nitin, Dye Justin, Ezzeldin Mohamad, Yoshimura Shinichi, Sconzo Daniel, Filo Jean, Pettersson Samuel, Fiorella David, Tanweer Omar, Romano Daniele G, Navia Pedro, Cuellar Hugo, Fragata Isabel, Polifka Adam, Mascitelli Justin, Osbun Joshua, Siddiqui Fazeel, Moss Mark, Limaye Kaustubh, Mokin Maxim, Matouk Charles, Park Min S, Brinjikji Waleed, Daglioglu Ergun, Williamson Richard, Altschul David J, Maier Ilko, Crosa Roberto, Gory Benjamin, Grandhi Ramesh, Paul Alexandra, Kan Peter, Casagrande Walter, Chowdhry Shakeel, Stiefel Michael F, Rai Ansaar, Spiotta Alejandro M, Taussky Philipp, Ogilvy Christopher S, Granstein Justin H
Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02115, USA.
Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
Transl Stroke Res. 2025 Sep 3. doi: 10.1007/s12975-025-01378-6.
The role of different imaging modalities-non-contrast CT (NCCT), CT perfusion (CTP), and diffusion-weighted imaging (DWI)-in selecting patients with large-core stroke for endovascular thrombectomy (EVT) is a subject of ongoing debate. This study aims to determine whether patients with large-core acute ischemic stroke (AIS) undergoing EVT triaged with CTP or DWI in addition to NCCT had different clinical outcomes compared to those only triaged with NCCT. We queried the Stroke Thrombectomy and Aneurysm Registry (STAR) for patients enrolled between 2014 and 2023 who presented with anterior-circulation AIS and large ischemic core (ASPECTS < 6) who underwent EVT in 41 stroke centers in the USA, Europe, Asia, and South America. Patients were stratified by the imaging used before EVT. Propensity score matching (PSM) was used to compare balanced cohorts of patients with NCCT vs CTP and NCCT vs DWI. The primary outcome was a favorable 90-day functional status (mRS 0-3). Secondary outcomes included intracerebral hemorrhage (ICH) rates, symptomatic ICH (sICH), and successful/complete recanalization, as determined by mTICI score. A total of 403 patients were included, 121 were selected with NCCT alone, 227 with CTP, and 55 with DWI. Before PSM, 90-day mRS 0-3, successful reperfusion mTICI ≥ 2B, and sICH rates were similar across the three imaging modalities. mTICI-2C or greater rates were highest in DWI (50.9%; p < 0.01), followed by NCCT (41.3%) and CTP (27.8%). Patients selected with CTP had the highest ICH incidence (44.1%; p < 0.01). After 1:1 PSM, 104 pairs of NCCT vs CTP and 36 pairs of NCCT vs DWI were compared. There were no significant differences in any procedural or functional outcome measure between the matched groups, including mTICI ≥ 2C recanalization, 90-day mRS 0-3, ICH rates, and sICH rates. In patients with anterior large-vessel occlusion AIS with low ASPECTS, we found that selecting patients for EVT based on NCCT or employing advanced imaging to elucidate collaterals, infarct volume, and ischemic penumbra does not alter procedural or patient outcomes. NCCT alone may be sufficient to select patients for EVT in this patient population, especially in settings with limited resources.
不同成像方式——非增强CT（NCCT）、CT灌注（CTP）和弥散加权成像（DWI）——在选择适合血管内血栓切除术（EVT）的大梗死核心卒中患者中的作用是一个仍在争论的话题。本研究旨在确定，对于接受EVT的大梗死核心急性缺血性卒中（AIS）患者，除NCCT外，采用CTP或DWI进行分诊与仅采用NCCT进行分诊相比，临床结局是否不同。我们查询了卒中血栓切除术和动脉瘤登记库（STAR），以获取2014年至2023年期间在美国、欧洲、亚洲和南美洲41个卒中中心接受EVT的前循环AIS且缺血核心较大（ASPECTS评分＜6）的患者。患者根据EVT前使用的成像方式进行分层。倾向评分匹配（PSM）用于比较NCCT与CTP以及NCCT与DWI的均衡患者队列。主要结局是90天时良好的功能状态（改良Rankin量表评分0 - 3分）。次要结局包括脑出血（ICH）发生率、症状性ICH（sICH）以及由脑梗死溶栓（mTICI）评分确定的成功/完全再通。共纳入403例患者，121例仅通过NCCT选择，227例通过CTP选择，55例通过DWI选择。在PSM之前，三种成像方式的90天改良Rankin量表评分0 - 3分、成功再灌注mTICI≥2B以及sICH发生率相似。mTICI - 2C或更高的发生率在DWI中最高（50.9%；p＜0.01），其次是NCCT（41.3%）和CTP（27.8%）。通过CTP选择的患者ICH发生率最高（44.1%；p＜0.01）。在1:1 PSM之后，比较了104对NCCT与CTP以及36对NCCT与DWI。匹配组之间在任何手术或功能结局指标上均无显著差异，包括mTICI≥2C再通、90天改良Rankin量表评分0 - 3分、ICH发生率和sICH发生率。在ASPECTS评分较低的前循环大血管闭塞性AIS患者中，我们发现基于NCCT选择患者进行EVT或采用先进成像来阐明侧支循环、梗死体积和缺血半暗带并不会改变手术或患者结局。在这一患者群体中，仅NCCT可能足以选择适合EVT的患者，尤其是在资源有限的情况下。
