Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective Multicenter Cohort Study of Imaging Selection

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective Multicenter Cohort Study of Imaging Selection:

Abstract

Objective

The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are non‐contrast CT(CT) and CT‐perfusion(CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes.

Methods

A phase‐II multicenter, prospective‐cohort study of large vessel occlusions who presented up‐to‐24hours from last‐known‐well was conducted. Patients received a unified pre‐specified imaging evaluation(CT, CT‐angiography, and CTP with RAPID software mismatch‐determination). The treatment decision, EVT vs Medical Management, was non‐randomized and at the treating physicians’ discretion. An independent blinded neuroimaging‐corelab adjudicated favorable profiles based on pre‐defined criteria(CT:ASPECTS≥6, CTP:rCBF(<30%)<70cc with mismatch‐ratio≥1.2 and mismatch‐volume≥10cc.

Results

Of 4722 screened from January/2016‐to‐February/2018, 361 patients were included. 285(79%) received EVT, of whom, 87.0% had favorable‐CTs; 91% favorable‐CTPs; 81% both favorable profiles , 16% discordant and 3% both unfavorable. Favorable profiles on the two modalities correlated similarly with 90‐day functional independence rates(favorable‐CT=56% vs favorable‐CTP=57%,aOR=1.91,95%CI=0.40‐9.01, p=0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR:3.97,95% CI=1.97‐8.01,p<0.001). 58% of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable(P<0.001 for trend). In favorable‐CT/unfavorable‐CTP profiles, EVT was associated with high sICH(24%) and mortality(53%) rates.

Interpretation

Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates but those with an unfavorable‐CTP had higher adverse outcomes.

Clinical‐Trial‐Registration: NCT02446587.https://clinicaltrials.gov/ct2/show/NCT02446587

This article is protected by copyright. All rights reserved.