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Department of Neurology, Peking University Third Hospital, Zhang Yun, Fu Yu, Fan Dongsheng
Editor's Note:
With the development of imaging and the concept of tissue window, we have gradually realized that there are individual differences in the ischemic semi-dark band of different patients, and even patients with overtime windows may have hope for treatment. Ischemic semi-dark belt is the key to the treatment of acute ischemic stroke (AIS), its evaluation and treatment is increasingly highly valued by clinicians, in this paper Professor Fan Dongsheng of the Third Hospital of Peking University combined with existing relevant research, as well as the latest content at the International Stroke Congress (ISC 2022), discussed the choice of endovascular treatment for AIS patients for the benefit of readers.
Ischemic semi-dark bands are assessed which are strong
Current AHA/ASA guidelines recommend endovascular therapy (EVT) in patients with early CT score (ASPECTS) of ≥6 in baseline Alberta stroke programs, as aspects of ≤5 are often considered to have major infarction, even with a poor prognosis for EVT. However, the correlation between baseline ASPECTS and infarct volume is limited. Data accumulated in recent years suggest that patients with low ASPECTS scores can still benefit from mechanical embolectomy [1-3].
Although aspect scoring is simple and easy, the volume of infarction may not be reliably predicted due to low consistency among scorers. Campbell et al. found in their analysis of HERMES data that CT whole brain perfusion imaging (CTP) assessing ischemic core volume independently associated with functional independence and functional improvement after EVT [4]. Aurora analysis found that the target perfusion-infarction mismatch compared to the clinical-image mismatch criteria screened more potential EVT beneficiaries, which provided more therapeutic feasibility for patients with 16 to 24 hours of onset [5], and suggested that the concept of EVT evaluation based on time window needed to gradually shift to the evaluation concept of tissue window (i.e., ischemic semi-dark band) quantified by image. However, the long duration of advanced perfusion imaging has led to delays in treatment, contrast agents and radiation exposure, and the need for imaging department cooperation, which has greatly limited its popularity.
There is no standard answer to the best screening method for the evaluation of ischemic semi-dark bands for emergency EVT by CT, CTP, and magnetic resonance perfusion (MRP).
The results of the CLEAR trial in a multicenter cohort study showed that the clinical outcome of CTP or MRI was not inferior to the clinical outcome of CTP or MRI when screened for transfiguration of suitable for embolectomy by CT scan, suggesting that CT scan can be used as a simpler, more widely used imaging examination, and has a promising application in the treatment decision of patients with hyperwindic retrieval [6]. However, the study has certain limitations, such as retrospective trial design, differences in imaging criteria for multicenter patients, and lack of important baseline assessments such as collateral circulation, so further guidance from prospective, multicenter, randomized studies is urgently needed for the screening of acute large core infarction for mechanical embolization.
ISC's latest research courier
The Japanese randomized controlled study RESCUE-Japan LIMIT showed that EVT was better than conservative drug treatment in patients with acute ischemic stroke with an ASPECTS score of 3-5 within 24 hours of onset. With the exception of intracranial hemorrhage, there were no differences in other safety measures between the two groups. Although some patients with large core infarction may benefit from EVT [7], since the study enrolled only in the Japanese population, with more than half patients with a time window of 4.5 hours, most patients with MRI screening, and intravenous thrombolytic doses of 0.6 mg/kg, it remains to be confirmed whether patients with large core infarction with a 24-hour time window and other populations worldwide benefit from EVT.
SELECT2 is a prospective, randomized, multi-country, multi-center, open-label controlled trial that evaluated results blindly and enrolled patients from 28 centers in the United States, Spain, Australia, New Zealand and Canada. Patients with pre-circulating large core infarction within 24 hours of CT ASPECTS, CTP, or MRP (CT ASPECTS score ≤5 or CTP/MRP showing ischemic core volume ≥50 ml defined as large core infarction) are randomly assigned to receive EVT or drug therapy (MM) in a 1:1 ratio. Of the 200 patients enrolled on October 19, 2021, 100 were randomly divided into the EVT group and the MM group. The time distributions of age, NIHSS, CT ASPECTS, onset to randomization were similar in both groups.
The study included a wide range of people, the distribution of key baseline data between the two groups is relatively consistent, it is expected that the results of the study can have some indications for the efficacy and safety of EVT in large core infarction within 24 hours, and by comparing CT, CTP, MRP to assess the effect of ischemic semi-dark belt emergency EVT, to specifically guide the embolic center to select appropriate imaging screening methods according to actual conditions for individualized embolectomy.
Do not rely too much on image evaluation
The current meta-analysis tells us that the outcomes of EMSIS 0-2 and 3-5 points may be different [8], so is it necessarily harmful to perform thrombotic retrieval in patients with acute ischemic stroke with ASPECTS 0-2? Although both RESCUE-Japan LIMIT and SELECT2 excluded patients with a SPECTRUMS score of 0-2, specific analysis was also required. Given that CT shows that some low-density lesions in the low-THANS region may reverse after rapid reperfusion, and that both ADC and CTP may overestimate the volume of the infarct core [9], some young patients with low bleeding risk of ASPECTS 0-2 may also need to consider embolectomy.
All images (including perfusion and sweeping) are a dynamic process based on the human body, and should not be too dependent on images to assess the risk of surgical benefit.
Although the volume of infarction is closely related to clinical prognosis, the specific location of the damage is equally important. Studies have shown that the right M6 region and the left internal capsule region have a more critical role in the prognosis of stroke due to the concentration of a large number of contact fibers that control spatial motor function [10]. Bouslama et al. found that age-adjusted PATIENTs with AIS who were not matched with NIHSSS-ASPECTS and who avoided the ASPECTS 6-10 pattern screening on the right M6 and left M4 had similar 90-day functional outcomes to those with DAWN and DEFUSE3-based perfusion mismatch screening. This may be a potential alternative for stroke centers where perfusion imaging is not available [11].
In addition, the evaluation of collateral circulation, whether to bridge intravenous thrombolysis [12], and the reasonable choice of surgical method can also affect the efficacy and safety of EVT in patients with AIS large core infarction. How to finely screen these patients still requires a lot of in-depth research.
References: (Swipe up and down to see more)
[1] Lancet Neurol. 2018 Oct;17(10):895-904.
[2] J Neurointerv Surg. 2020 Aug;12(8):747-752.
[3] Eur J Neurol. 2018 Jan;25(1):105-110.
[4] Lancet Neurol. 2019 Jan;18(1):46-55.
[5] JAMA Neurol. 2021 Sep 1;78(9):1064-1071.
[6] JAMA Neurol. 2022 Jan 1;79(1):22-31.
[7] N Engl J Med. 2022 Feb 9.
[8] J Neurointerv Surg. 2020 Apr;12(4):350-355.
[9] Stroke. 2021 May;52(5):1751-1760.
[10] Neurology. 2020 Dec 15;95(24):1078-1079.
[11] J Neurol Neurosurg Psychiatry. 2021 Nov;92(11):1152-1157.
[12] Stroke. 2021 Mar;52(3):1098-1104.
Expert Profiles
Fan Dongsheng
Professor, Peking University Third Clinic
Director of the Department of Neurology, Peking University Third Hospital, Director of the Department of Neurology, Peking University Health Science Center, Director of the Beijing Key Laboratory of Biomarker Research and Transformation of Neurodegenerative Diseases, Deputy Director of the Academic Committee of the Key Laboratory of Neuroscience of the Ministry of Education, And Deputy Director of the Academic Committee of the Key Laboratory of Neuroscience of the National Health Commission.
He was awarded the Tugong Expert of the National Health Commission, the "Famous Doctor of the Country" Outstanding Achievement Award, and the "Outstanding Contribution Award" of the Stroke Prevention and Control Engineering Committee of the National Health Commission. He has published more than 600 papers, with an H index of 43; cited 7581 times; among which SCI includes a cumulative impact factor of 743.859. He has won the first prize of scientific and technological progress of the Ministry of Education and the second prize of natural science. He presided over Peking University's "Neurology" and won the "National Excellent Course", and is now the "New Era" teaching reform of Peking University.COM.
He is currently a director of AOCCN, the chairman of the Free Radical Medicine Branch of the Chinese Preventive Medicine Association, the chairman-elect of the Neurology Branch of the Beijing Medical Association, the leader of the Electromyography and Clinical Neurophysiology Group of the Neurology Branch of the Chinese Medical Association/Neurology Branch of the Chinese Medical Doctor Association, the chairman of the Brain and Vascular Branch of the Chinese Society of Cardiothoracic and Vascular Anesthesiology, the chairman of the Geriatric Cerebrovascular Disease Branch of the Chinese Geriatric Health Care Medical Research Association, and the supervisor of the Chinese Stroke Society.
(Source: Editorial Board of International Circulation)
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