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Original Investigation |

Comparison of Final Infarct Volumes in Patients Who Received Endovascular Therapy or Intravenous Thrombolysis for Acute Intracranial Large-Vessel Occlusions

Srikant Rangaraju, MD1; Kumiko Owada, MD1; Ali Reza Noorian, MD1; Raul G. Nogueira, MD1; Fadi Nahab, MD1; Brenda A. Glenn, RN, BSN, ACNP1; Samir R. Belagaje, MD1; Aaron M. Anderson, MD1; Michael R. Frankel, MD1; Rishi Gupta, MD1
[+] Author Affiliations
1Department of Neurology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia.
JAMA Neurol. 2013;70(7):831-836. doi:10.1001/jamaneurol.2013.413.
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Importance  Studies comparing the efficacy of intra-arterial therapy (IAT) and medical therapy in reducing final infarct volume (FIV) in intracranial large-vessel occlusions (ILVOs) are lacking.

Objectives  To assess whether patients with ILVOs who received IAT have smaller FIVs than patients who received either intravenous tissue plasminogen activator therapy (IVT) or no reperfusion therapy (NRT) and to determine a National Institutes of Health Stroke Scale (NIHSS) threshold score that identifies patients most likely to benefit from IAT.

Design  Retrospective cohort study of patients with ILVOs between 2009 and 2011.

Setting  Two large-volume stroke centers.

Participants  Adults with anterior circulation ILVOs who presented within 360 minutes from the time last seen as normal. Patients with isolated extracranial occlusions were not included.

Exposure  Intra-arterial therapy, IVT, or NRT.

Main Outcomes and Measures  Final infarct volumes, rates of acceptable outcome defined as a modified Rankin Scale score of 0 to 3 at hospital discharge, and NIHSS threshold scores.

Results  A total of 203 consecutive patients with ILVOs were evaluated. Baseline characteristics were similar among the 3 groups. The median infarct volume was significantly smaller for the IAT group (42 cm3) than for the IVT group (109 cm3; P = .001) or the NRT group (110 cm3; P < .01). A higher magnitude of infarct volume reduction in more proximal occlusions was noted in the IAT group compared with the IVT and NRT groups combined: internal carotid artery terminus (75 vs 190 cm3; P < .001), M1 middle cerebral artery (39 vs 109 cm3; P = .004), and M2 middle cerebral artery (33 vs 59 cm3; P = .04) occlusions. Patients were stratified based on NIHSS score at presentation (8-13, 14-19, and ≥20). For patients with an NIHSS score of 14 or higher at presentation, IAT significantly reduced FIV (46 cm3 with IAT vs 149 cm3 with IVT or NRT; P < .001) compared with patients with an NIHSS score of 8 to 13 (22 cm3 with IAT vs 44 cm3 with IVT or NRT; P = .40). Patients with an NIHSS score of 14 or higher who received IAT appear to benefit most from IAT.

Conclusions and Relevance  Our data suggest a greater reduction of FIV with IAT compared with either IVT or NRT. Moreover, patients with an NIHSS score of 14 or higher may be the best candidates for endovascular reperfusion therapy.

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Figure 1.
Comparison of Median Infarct Volumes in 3 Therapy Groups

Box and whisker plots comparing median infarct volumes in the intra-arterial therapy (IAT), intravenous tissue plasminogen activator therapy (IVT), and no reperfusion therapy (NRT) groups (A) and in the IAT and IVT/NRT groups based on level of occlusion. The horizontal line in the middle of each box indicates the median, while the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers above and below the box mark the 90th and 10th percentiles. The points beyond the whiskers are outliers beyond the 90th percentile. ICA-T, indicates internal carotid artery terminus; MCA, middle cerebral artery.

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Figure 2.
NIHSS Scores and Infarct Volumes

A, Box and whisker plot comparing median infarct volumes in the intra-arterial therapy (IAT) group and in the intravenous tissue plasminogen activator therapy and no reperfusion therapy groups combined (IVT/NRT) based on National Institutes of Health Stroke Scale (NIHSS) scores at presentation. The horizontal line in the middle of each box indicates the median, while the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers above and below the box mark the 90th and 10th percentiles. The points beyond the whiskers are outliers beyond the 90th percentile. B, Proportion of patients with an acceptable clinical outcome (ie, a modified Rankin Scale [mRS] score of 0-3 at hospital discharge) in the IAT and IVT/NRT groups. Intra-arterial therapy reduces infarct volume and improves clinical outcomes in patients with an intracranial large-vessel occlusion who had an NIHSS score of 14 or greater at presentation.

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