J Stroke.  2024 May;26(2):260-268. 10.5853/jos.2023.02621.

Infarcts Due to Large Vessel Occlusions Continue to Grow Despite Near-Complete Reperfusion After Endovascular Treatment

• Ospel JM
• Rex N
• Oueidat K
• McDonough R
• Rinkel L
• Baird G
• Collins S
• Jindal G
• Alvin MD
• Boxerman J
• Barber P
• Jayaraman M
• Smith W
• Amirault-Capuano A
• Hill MD
• Goyal M
• McTaggart R

• KMID: 2556046
• DOI: http://doi.org/10.5853/jos.2023.02621

Abstract

Background and Purpose
Infarcts in acute ischemic stroke (AIS) patients may continue to grow even after reperfusion, due to mechanisms such as microvascular obstruction and reperfusion injury. We investigated whether and how much infarcts grow in AIS patients after near-complete (expanded Thrombolysis in Cerebral Infarction [eTICI] 2c/3) reperfusion following endovascular treatment (EVT), and to assess the association of post-reperfusion infarct growth with clinical outcomes.
Methods
Data are from a single-center retrospective observational cohort study that included AIS patients undergoing EVT with near-complete reperfusion who received diffusion-weighted magnetic resonance imaging (MRI) within 2 hours post-EVT and 24 hours after EVT. Association of infarct growth between 2 and 24 hours post-EVT and 24-hour National Institutes of Health Stroke Scale (NIHSS) as well as 90-day modified Rankin Scale score was assessed using multivariable logistic regression.
Results
Ninety-four of 155 (60.6%) patients achieved eTICI 2c/3 and were included in the analysis. Eighty of these 94 (85.1%) patients showed infarct growth between 2 and 24 hours post-reperfusion. Infarct growth ≥5 mL was seen in 39/94 (41.5%) patients, and infarct growth ≥10 mL was seen in 20/94 (21.3%) patients. Median infarct growth between 2 and 24 hours post-reperfusion was 4.5 mL (interquartile range: 0.4–9.2 mL). Post-reperfusion infarct growth was associated with the 24-hour NIHSS in multivariable analysis (odds ratio: 1.16 [95% confidence interval 1.09–1.24], P<0.01).
Conclusion
Infarcts continue to grow after EVT, even if near-complete reperfusion is achieved. Investigating the underlying mechanisms may inform future therapeutic approaches for mitigating the process and help improve patient outcome.

Keyword

Stroke; Infarct growth; Ischemia; Thrombectomy; Reperfusion

Figure

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  Figure 1. Flowchart with included and excluded patients. EVT, endovascular treatment; MRI, magnetic resonance imaging; ICA, internal carotid artery; eTICI, expanded Thrombolysis in Cerebral Infarction score.

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  Figure 2. Infarct growth between 2 and 24 hours post-EVT in the 94 patients with eTICI 2c/3 that were included in the analysis. Waterfall chart in (A) shows infarct growth as bars, whereby the left end of the bar denotes the infarct volume 2 hours post-EVT, and the right end of the bar denotes the infarct volume 24 hours post-EVT. Blue bars indicate infarct growth between 2 and 24 hours, green bars indicate infarct shrinkage between 2 and 24 hours. (B) shows the number and percent of patients with infarct growth <0 mL (infarct shrinkage), infarct growth between 0 and <5 mL, between 5 and <10 mL, and ≥10 mL between 2 hours and 24 hours post-EVT. EVT, endovascular treatment; eTICI, expanded Thrombolysis in Cerebral Infarction score.

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  Figure 3. Infarct volume (DWI lesion volume) at the initial MRI (within 2 hours from EVT) and at 24 hours after EVT. The black line illustrates the change for all patients along with 95% confidence limits. The colored lines are individual patients, demonstrating the range of initial infarct volumes and their trajectory at 24 hours. (A) Infarct volumes ranging from 0 mL to 200 mL. (B) Infarct volumes ranging from 0 mL to 70 mL. DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging; EVT, endovascular treatment.

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  Figure 4. Pre-stroke and 90-day modified Rankin Scale (mRS) score (A) and pre-stroke and 24-hour National Institutes of Health Stroke Scale (NIHSS) (B). The black line illustrates the change for all patients along with 95% confidence limits. The colored lines are individual patients, demonstrating the range of initial and 90-day mRS/initial and 24-hour NIHSS.

Reference

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