Abstract 41: Conventional vs Advanced Imaging for the Selection of Stroke Therapy in the Extended Window (VESTA Study)

Abstract

Background: The optimal imaging modality for treatment selection in the extended stroke window is uncertain. VESTA study (NCT05299034) compared conventional imaging (noncontrast CT + CT angiography) with advanced imaging (adding perfusion) in extended window stroke patients, focusing on EVT selection rate, safety and functional outcome. Methods: From the prospective Catalan Stroke Registry (CICAT, 29 centers) ischemic stroke patients within 6-24h of symptom onset and NIHSS ≥6 (Jan 2019 -Dec 2021) were selected. Imaging modality was decided according to the local site protocol. Images were re-evaluated by a central core lab with full access to each patient’s images. LVO was defined as intracranial ICA, M1 or proximal M2 occlusion. Blinded investigators centrally assessed 90-day functional independence, defined as mRS≤2. We employed a propensity score matching algorithm to adjust for age, sex, NIHSS, established infarct, and time from onset to arrival. Results: We included 1405 patients in the analysis (median age 76y, median NIHSS 11; 48% women). Conventional imaging was performed in 48% of patients, while 52% received advanced imaging. Patients receiving conventional vs. advanced imaging showed lower NIHSS (11 vs. 12, p=0.006), and lower rates of LVO (45% vs. 58%, p<0.001) and EVT indication (33% vs. 41%, p=0.01). Demographics and time metrics were comparable between techniques. The matched adjusted analysis showed no differences between modalities in 90-day functional independence (OR=0.9 [0.7;1.2]), mortality (1.18 [0.9;1.6]), or symptomatic hemorrhage (OR=1.35 [0.47;3.8]). The figure displays subgroup analysis for patients arriving at a comprehensive stroke center and for patients with anterior LVO. Conclusions: Advanced imaging allowed the identification of more occlusions and the selection of more patients for EVT; however, patients undergoing either conventional or advanced imaging had similar clinical outcomes at 90 days.