Abstract 9: Perfusion-based Selection Leads To Improved Outcomes Compared With Time-based Selection For Endovascular Reperfusion Therapy In Acute Ischemic Stroke

Abstract

Background: Controversy exists on the role of perfusion imaging-based selection of patients with acute ischemic stroke (AIS) for endovascular reperfusion therapy (ERT). We hypothesized that perfusion imaging based selection would improve functional outcomes at 3 months compared to time based selection alone. Methods: We reviewed consecutive patients with anterior circulation strokes, baseline NIHSS score > 8, and treated with ERT at 4 centers between 2006 and 2011. Data were collected on demographics, initial NIHSS score, intravenous tissue plasminogen activator (IV tPA), use of perfusion imaging (CT or MRI), time from onset to groin puncture, reperfusion grade using the modified TICI scale, symptomatic hemorrhage, and functional outcome using the modified Rankin Scale (mRS) at 3 months. Using univariable statistics and multivariable logistic regression, we assessed whether patients who underwent perfusion imaging had better outcomes than those selected based on time alone. Results: One-hundred eighty-five patients (mean age 66.7 years; median NIHSS score 19; MCA occlusion 73% and ICA occlusion 27%) were included. TICI 2b or 3 reperfusion grade was achieved in 49.7% while symptomatic hemorrhage (PH1, PH2, or perforation) occurred in 10.8%. Perfusion imaging was used in 69 (37.3%) patients (45 CT and 24 MRI) and was associated with increased onset-to-groin puncture time (359 vs. 298 minutes, P=0.019). Patients who underwent perfusion imaging were also older (73 vs. 63 years, P<0.001). Overall, good outcome (mRS 0-2) at 3 months was seen in 41.7% of patients. Those who underwent perfusion imaging were more likely to have good outcomes (53.6 vs. 34.5%, P=0.011). In multivariable analysis, perfusion imaging remained a predictor of good outcome (adj. OR 2.35, 95% CI 1.17-4.72), independent of initial NIHSS score, TICI 2b or 3 reperfusion, and IV tPA use. Conclusions: In this multi-center observational study, patients with AIS who underwent perfusion imaging were over 2-fold more likely to have good outcomes following ERT despite a delay in time to treatment and advanced age compared to time-based selected patients. Further studies should continue to address the optimal perfusion imaging criteria for patient selection for ERT.