What Is the "Optimal" Target Mismatch Criteria for Acute Ischemic Stroke?

Chushuang Chen; Mark W Parsons; Christopher R Levi; Neil J Spratt; Longting Lin; Timothy Kleinig; Kenneth Butcher; Xin Cheng; Qiang Dong; Billy O'Brien; Richard I Avivi; Martin Krause; P N Sylaja; Philip Choi; Sandeep Bhuta; Congguo Yin; Jianhong Yang; Peng Wang; Weiwen Qiu; Andrew Bivard

doi:10.3389/fneur.2020.590766

What Is the "Optimal" Target Mismatch Criteria for Acute Ischemic Stroke?

Front Neurol. 2021 Jan 13:11:590766. doi: 10.3389/fneur.2020.590766. eCollection 2020.

Authors

Chushuang Chen¹, Mark W Parsons², Christopher R Levi^{3

4}, Neil J Spratt^{3

4}, Longting Lin², Timothy Kleinig⁵, Kenneth Butcher⁶, Xin Cheng⁷, Qiang Dong⁷, Billy O'Brien⁸, Richard I Avivi⁹, Martin Krause¹⁰, P N Sylaja¹¹, Philip Choi¹², Sandeep Bhuta¹³, Congguo Yin¹⁴, Jianhong Yang¹⁵, Peng Wang¹⁶, Weiwen Qiu¹⁷, Andrew Bivard¹

Affiliations

¹ Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia.
² Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia.
³ Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.
⁴ Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
⁵ Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia.
⁶ Prince of Wales Medical School, University of New South Wales, Sydney, NSW, Australia.
⁷ Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
⁸ Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
⁹ Division of Neuroradiology, Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁰ Department of Neurology, Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia.
¹¹ Department of Neurology, Sri Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
¹² Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia.
¹³ Department of Medical Imaging, Gold Coast University Hospital, Southport, QLD, Australia.
¹⁴ Department of Neurology, Hangzhou First Hospital, Zhejiang, China.
¹⁵ Department of Neurology, Ningbo First Hospital, Zhejiang, China.
¹⁶ Department of Neurology, Taizhou First People's Hospital, Zhejiang, China.
¹⁷ Department of Neurology, Lishui People's Hospital, Zhejiang, China.

Abstract

We aimed to compare Perfusion Imaging Mismatch (PIM) and Clinical Core Mismatch (CCM) criteria in ischemic stroke patients to identify the effect of these criteria on selected patient population characteristics and clinical outcomes. Patients from the INternational Stroke Perfusion Imaging REgistry (INSPIRE) who received reperfusion therapy, had pre-treatment multimodal CT, 24-h imaging, and 3 month outcomes were analyzed. Patients were divided into 3 cohorts: endovascular thrombectomy (EVT), intravenous thrombolysis alone with large vessel occlusion (IVT-LVO), and intravenous thrombolysis alone without LVO (IVT-nonLVO). Patients were classified using 6 separate mismatch criteria: PIM-using 3 different measures to define the perfusion deficit (Delay Time, Tmax, or Mean Transit Time); or CCM-mismatch between age-adjusted National Institutes of Health Stroke Scale and CT Perfusion core, defined as relative cerebral blood flow <30% within the perfusion deficit defined in three ways (as above). We assessed the eligibility rate for each mismatch criterion and its ability to identify patients likely to respond to treatment. There were 994 patients eligible for this study. PIM with delay time (PIM-DT) had the highest inclusion rate for both EVT (82.7%) and IVT-LVO (79.5%) cohorts. In PIM positive patients who received EVT, recanalization was strongly associated with achieving an excellent outcome at 90-days (e.g., PIM-DT: mRS 0-1, adjusted OR 4.27, P = 0.005), whereas there was no such association between reperfusion and an excellent outcome with any of the CCM criteria (all p > 0.05). Notably, in IVT-LVO cohort, 58.2% of the PIM-DT positive patients achieved an excellent outcome compared with 31.0% in non-mismatch patients following successful recanalization (P = 0.006). Conclusion: PIM-DT was the optimal mismatch criterion in large vessel occlusion patients, combining a high eligibility rate with better clinical response to reperfusion. No mismatch criterion was useful to identify patients who are most likely response to reperfusion in non-large vessel occlusion patients.

Keywords: endovascular thrombectomy; intravenous thrombolysis; ischemic stroke; perfusion; target mismatch.