CT Perfusion Imaging After Selection for Late-Window Endovascular Stroke Treatment
Authors: Susanne G. H. Olthuis, Florentina M. E. Pinckaers, M. M. Quirien Robbe, Inger R. de Ridder, Jan W. Hoving, Esmee Venema, Jasper D. Daems, F. A. V. (Anne) Pirson, Julie Staals, Bart J. Emmer, Hester F. Lingsma, Stefan D. Roosendaal, Anouk van der Hoorn, Miou S. Koopman, Alida A. Postma, Diederik W. J. Dippel, Charles B. Majoie, Robert J. van Oostenbrugge, Wim H. van Zwam, Robert J. Oostenbrugge, van, Wim H. Zwam, Susanne G. H. Olthuis, Florentina M. E. Pinckaers, Inger R. Ridder, de, F.A.V. (Anne) Pirson, M. M. Quirien Robbe, Jan W. Hoving, Hester F. Lingsma, Julie Staals, Bart J. Emmer, Stefan D. Roosendaal, Anouk Hoorn, van der, Alida A. Postma, Diederik W. J. Dippel, Charles B. Majoie, Aad Lugt, van der, Adriaan C. G. M. Es, van, Bob Roozenbeek, Pieter-Jan Doornmaal, van, Yvo B. W. E. M. Roos, Jonathan M. Coutinho, Bart Worp, van der, Rob T. H. Lo, Marianne A. A. Walderveen, van, Marieke J. H. Wermer, Ewoud I. Dijk, van, Sjoerd Jenniskens, H. D. (Jeroen) Boogaarts, Maarten Uyttenboogaart, Reinoud P. H. Bokkers, Koos Keizer, Rob A. R. Gons, Lonneke S. F. Yo, Heleen M. Hertog, den, Boudewijn A. A. M Hasselt, van, Wouter J. Schonewile, Jan-Albert Vos, Julia H. Tuijl, van, Issam Boukrab, Hans G. Kortman, Jeannette Hofmaijer, Jasper M. Martens, Ido R. Wijngaard, van den, Jelis Boiten, Geert J. Lycklama à Nijeholt, Paul J. A. M. Brouwers, Emiel J. C. Sturm, Tomas Bulut, Karlijn F. Laat, de, Lukas C. Dijk, van, Michel J. M. Remmers, Thijs E. A. M. Jong, de, Anouk D. Rozeman, Otto E.H. Elgersma, Bas Veen, van der, Davy R. Sudiono, Heinrich Mattle, Jens Fiehler, Sander Kuijk, Daan Nieboer, Rick Nuland, van, G. M. (Menno) Krietemeijer, René Berg, van den, Ludo Beenen, Sebastiaan Hammer, Anton Meijer, Anouk D. Hoorn, van der, Albert J. Yoo, Dick Gerrits, Ben P. W. Jansen, Martine T. B. Truijman, Sanne M. Manschot, Henk Kerkhoff, Peter J. Koudstaal, Vicky Chalos, Olvert A. Berkhemer, Andriaan Versteeg, Lennard Wolff, Jiahang Su, P. M. (Matthijs) Sluijs, van der, Henk Voorst, van, Manon Tolhuisen, Hugo Cate, ten, Moniek P. M. Maat, de, Samantha Donse-Donkel, Heleen M. M. Beusekom, Aladdin Taha, Aarazo Barakzie, Wouter H. Hinsenveld, Robert-Jan B. Goldhoorn, Kilian Treurniet, Sophie Berg, van den, Natalie LeCouffe, Rob Graaf, van de, Angelique Ceulemans, Robrecht R. M. M. Knapen, Lotte Sontag, Rik Reinink, Suzanne M. Silvis, Floris H. B. M. Schreuder, Simone Uniken Venema, Laura C. C. Meenen, van, Sabine Collete, Wilma Wijngaarden, van, Wouter Steen, van der, Sabrina P. J. H. Verheesen, Martin Sterrenberg, Naziha Ghannouti, El, Rita Sprengers, Ayla Ahee, van, Berber Zweedijk, Wilma Pellikaan, Irati Schonewile, Kitty Blauwendraat, Yvonne Drabbe, Anke Kleine-Kathöfer, Joke Meris, de, Michelle Sandiman, Tamara Dofferhoff-Vermeulen, Michelle Simons, Hester Bongenaar, Maylee Smallegange, Anja Loon, van, Karin Kraus, Erna Bos-Verheij, Esther Santegoets, Suze Kooij, Annemarie Slotboom, Eva Ponjee, Rieke Eilander, Hanneke Droste, Esther Veen, van, Rosalie Visser, Jasmijn Lodico, Marieke Jong, de, Friedus Minne, van der, Eefje Cleophas, Ernst B. Muskens, Amy Nijst, Leontien Heiligers, Yvonne Martens, Miranda Slotboom, Rogier G. Hintzen, Bart C. Jacobs
Journal: JAMA Neurology (2025)

Importance MR CLEAN-LATE (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands for Late Arrivals) showed efficacy of endovascular treatment (EVT) in the late window (6-24 hours after stroke symptom onset or time last seen well) among patients with ischemic stroke selected based on collateral flow. Therefore, the future role of computed tomography perfusion (CTP) imaging in patient selection for late-window EVT may change. Objective To investigate the interaction among CTP parameters (core volumes, penumbra volumes, and mismatch ratio) and the association of EVT with functional outcomes among patients in the late window after ischemic stroke selected based on collateral flow. Design, Setting, and Participants This is a post hoc secondary analysis of MR CLEAN-LATE, a multicenter randomized clinical trial, with open-label treatment and blinded end point, conducted from February 2, 2018, to January 27, 2022, in 18 Dutch stroke intervention centers. Participants included 502 patients with anterior circulation large vessel occlusion and present collateral flow on results of computed tomographic angiography in the late window after stroke, who gave deferred consent and were included in MR CLEAN-LATE. All patients had completed follow-up at 90 days. This secondary analysis included 313 patients (62%) with available CTP results. Statistical analysis was performed in September 2023. Intervention Patients were randomized to receive EVT (EVT group) and best medical management vs best medical management alone (no EVT group). Main Outcomes and Measures The primary outcome was functional outcome at 90 days measured by the modified Rankin Scale score. The treatment effect was analyzed in subgroups of core volumes, penumbra volume, and mismatch ratios using ordinal regression analysis. An interaction analysis was performed to assess whether CTP parameters modified the EVT effect on the modified Rankin Scale score at 90 days. All analyses were adjusted for relevant prognostic factors. Results Among the 313 patients (158 women [50%]) in the study, the median age was 73 years (IQR, 63-80 years), and the EVT group had fewer male participants than the no EVT group (73 of 168 [43%] vs 82 of 145 [57%]). Penumbra volumes significantly modified the association of EVT with outcomes ( P &amp;amp;lt; .001 for interaction), with the largest effect size among patients with penumbras of 120 mL or more (adjusted common odds ratio [ACOR], 6.89 [95% CI, 2.96-16.04]) and the smallest effect size among patients with penumbras of 72 mL or less (ACOR, 0.49 [95% CI, 0.22-1.08]). Core volume and mismatch ratio did not modify the EVT effect. Conclusions and Relevance Based on results from this secondary analysis of the MR CLEAN-LATE randomized clinical trial, there was a direct interaction between penumbra volume and treatment effect, and a trend toward potential harm of EVT was seen among patients with the smallest penumbras, which warrants further research. However, core volume and mismatch ratio did not seem to have additional value in patient selection. Trial Registration isrctn.org Identifier: ISRCTN19922220