Relevance of Brain Regions’ Eloquence Assessment in Patients With a Large Ischemic Core Treated With Mechanical Thrombectomy.
Neurology. 2021-11-16; 97(20):
DOI: 10.1212/wnl.0000000000012863
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Kerleroux B(1), Benzakoun J(2), Janot K(2), Dargazanli C(2), Eraya DD(2), Ben
Hassen W(2), Zhu F(2), Gory B(2), Hak JF(2), Perot C(2), Detraz L(2), Bourcier
R(2), Aymeric R(2), Forestier G(2), Marnat G(2), Gariel F(2), Mordasini P(2),
Seners P(2), Turc G(2), Kaesmacher J(2), Oppenheim C(2), Naggara O(2), Boulouis
G(2); JENI Research Collaborative.
Collaborators: Fischer U, Gralla J, Mosimann PJ, Arnold M, Meinel TR, Costalat
V, Benali A, Derraz I, Lefevre PH, Gascou G, Riquelme C, Bonafe A, Le Bars E,
Moynier M, Barreau X, Berge J, Menegon P, Tourdias T, Lucas L, Sibon I, Saleme
S, Mounayer C, Girard N, Bartoli JM, Brunel H, Testud B, Puech B, Laksiri N,
Robinet E, Pelletier J, Herbreteau D, Bibi R, Narata AP, Boustia F, Maldonado I,
Cottier JP, Gaudron M, Annan M, Meder JF, Trystram D, Rodriguez C, Edjlali M,
Desal H, Daumasduport B, Lallinec V, Lenoble C, Alexandre PL, Bracard S,
Anxionnat R, Degrelle AL, Tonnelet R, Lao L, Richard S, Humbertjean L, Mione G,
Labour JC.
Author information:
(1)From INSERM U1266 (B.K., J.B., W.B.H., C.O., O.N.), Institut of Psychiatry
and Neuroscience (IPNP), UMR_S1266, INSERM, Université de Paris, GHU Paris
Psychiatrie et Neurosciences, Site Sainte-Anne; Diagnostic and Therapeutic
Neuroradiology (K.J., G.B.), CHRU de Tours; Department of Interventional
Neuroradiology (C.D., D.D.E.), University Hospital Center of Montpellier, Gui de
Chauliac Hospital; Department of Diagnostic and Therapeutic Neuroradiology,
CHRU-Nancy (F.Z., B.G.), IADI, INSERM U1254 (F.Z., B.G.), and ADI U1254 (F.Z.,
G.B.) Université de Lorraine, Nancy; Department of Diagnostic and Interventional
Neuroradiology (J.-F.H.) and Neurology Department (C.P.), APHM, Cedex, Timone
Hospital, Aix Marseille University; Department of Diagnostic and Interventional
Neuroradiology (L.D., R.B.), Guillaume et René Laennec University Hospital,
Nantes; Department of Interventional Neuroradiology (R.A., G.F.), Dupuytren
University Hospital, Limoges; Department of Diagnostic and Interventional
Neuroradiology (G.M., F.G.), Pellegrin Hospital-University Hospital of Bordeaux,
France; Institute of Diagnostic, Interventional and Pediatric Radiology and
Institute of Diagnostic and Interventional Neuroradiology (P.M., J.K.),
University Hospital Bern, Inselspital, University of Bern, Switzerland;
Neurology Department (P.S.), Fondation Rothschild Hospital, Paris; Neurology
Department (G.T.), GHU Paris Psychiatrie et Neurosciences, Université de Paris,
INSERM U1266, FHU NeuroVasc; and Neuroradiology Department (G.B.), Université de
Paris, des Neurosciences Psychiatrie de Paris, France.
.
(2)From INSERM U1266 (B.K., J.B., W.B.H., C.O., O.N.), Institut of Psychiatry
and Neuroscience (IPNP), UMR_S1266, INSERM, Université de Paris, GHU Paris
Psychiatrie et Neurosciences, Site Sainte-Anne; Diagnostic and Therapeutic
Neuroradiology (K.J., G.B.), CHRU de Tours; Department of Interventional
Neuroradiology (C.D., D.D.E.), University Hospital Center of Montpellier, Gui de
Chauliac Hospital; Department of Diagnostic and Therapeutic Neuroradiology,
CHRU-Nancy (F.Z., B.G.), IADI, INSERM U1254 (F.Z., B.G.), and ADI U1254 (F.Z.,
G.B.) Université de Lorraine, Nancy; Department of Diagnostic and Interventional
Neuroradiology (J.-F.H.) and Neurology Department (C.P.), APHM, Cedex, Timone
Hospital, Aix Marseille University; Department of Diagnostic and Interventional
Neuroradiology (L.D., R.B.), Guillaume et René Laennec University Hospital,
Nantes; Department of Interventional Neuroradiology (R.A., G.F.), Dupuytren
University Hospital, Limoges; Department of Diagnostic and Interventional
Neuroradiology (G.M., F.G.), Pellegrin Hospital-University Hospital of Bordeaux,
France; Institute of Diagnostic, Interventional and Pediatric Radiology and
Institute of Diagnostic and Interventional Neuroradiology (P.M., J.K.),
University Hospital Bern, Inselspital, University of Bern, Switzerland;
Neurology Department (P.S.), Fondation Rothschild Hospital, Paris; Neurology
Department (G.T.), GHU Paris Psychiatrie et Neurosciences, Université de Paris,
INSERM U1266, FHU NeuroVasc; and Neuroradiology Department (G.B.), Université de
Paris, des Neurosciences Psychiatrie de Paris, France.
Comment in
Neurology. 2021 Nov 16;97(20):927-928.
OBJECTIVE: Individualized patient selection for mechanical thrombectomy (MT) in
patients with acute ischemic stroke (AIS) and large ischemic core (LIC) at
baseline is an unmet need. We tested the hypothesis that assessing the
functional relevance of both infarcted and hypoperfused brain tissue would
improve the selection framework of patients with LIC for MT.
METHODS: We performed a multicenter, retrospective study of adults with LIC
(ischemic core volume >70 mL on MRI diffusion-weighted imaging) with MRI
perfusion treated with MT or best medical management (BMM). Primary outcome was
3-month modified Rankin Scale (mRS), favorable if 0-3. Global and regional
eloquence-based core perfusion mismatch ratios were derived. The predictive
accuracy for clinical outcome of eloquent regions involvement was compared in
multivariable and bootstrap random forest models.
RESULTS: A total of 138 patients with baseline LIC were included (MT n = 96 or
BMM n = 42; mean age ± SD, 72.4 ± 14.4 years; 34.1% female; mRS 0-3: 45.1%).
Mean core and critically hypoperfused volume were 100.4 mL ± 36.3 mL and 157.6 ±
56.2 mL, respectively, and did not differ between groups. Models considering the
functional relevance of the infarct location showed a better accuracy for the
prediction of mRS 0-3 with a c statistic of 0.76 and 0.83 for logistic
regression model and bootstrap random forest testing sets, respectively. In
these models, the interaction between treatment effect of MT and the mismatch
was significant (p = 0.04). In comparison, in the logistic regression model
disregarding functional eloquence, the c statistic was 0.67 and the interaction
between MT and the mismatch was insignificant.
CONCLUSIONS: Considering functional eloquence of hypoperfused tissue in patients
with a large infarct core at baseline allows for a more precise estimation of
treatment expected benefit.
CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that, in
patients with AIS and LIC, considering the functional eloquence of the infarct
location improves prediction of disability status at 3 months.
© 2021 American Academy of Neurology.