AJNR Am J Neuroradiol. 2026 Feb 3;47(2):350-356. doi: 10.3174/ajnr.A9066.
ABSTRACT
BACKGROUND AND PURPOSE: Endovascular thrombectomy (EVT) is an effective treatment of acute ischemic stroke caused by large-vessel occlusion (AIS-LVO) of the anterior circulation, and technical success is essential to maximize outcomes. Increased EVT pass counts have been associated with reduced procedural efficacy and worse patient outcomes. We examined the impact of pre-EVT cerebral perfusion imaging parameters on clinical outcomes in patients with high EVT pass numbers.
MATERIALS AND METHODS: We performed a multicenter retrospective analysis of patients with AIS-LVO who had pretreatment CTA and CTP imaging and a pass count ≥3. Baseline NCCT imaging was analyzed according to ASPECTS. Ischemic core was defined as relative CBF <30% on CTP. Collateral blood flow was evaluated using the modified Tan scoring system on CTA, hypoperfusion intensity ratio (time-to-maximum >10 seconds/>6-second volumetric ratio) on CTP, and venous outflow (VO) on CTA. The primary outcome was favorable clinical outcomes (mRS 0-2) at 90 days.
RESULTS: One hundred seventy-eight patients met the inclusion criteria and were dichotomized into favorable (mRS 0-2, 29%) and unfavorable outcome (mRS 3-6, 71%) groups. Patients with favorable outcomes had lower blood glucose levels (mean, 115 mg/dL; interquartile range [IQR], 102-128 versus 126 mg/dL [IQR, 103-156; P = .03) and lower baseline NIHSS scores (median, 9; IQR, 6.5-13.5 versus 17; IQR, 13-20; P < .001) compared with those with unfavorable outcomes. On pre-EVT imaging, favorable patients had smaller ischemic core volumes (median, 2 mL; IQR, 0-14 versus 16 mL; IQR, 0-39; P < .001), higher ASPECTS (median, 9; IQR, 7-10 versus 7; IQR, 6-9; P = .001), a higher frequency of favorable CTA collaterals (87% versus 57%, P < .001), a more favorable hypoperfusion intensity ratio (median, 0.3; IQR, 0.2-0.5 versus 0.5; IQR, 0.4-0.6; P < .001), and higher rates of favorable VO (73% versus 15%; P < .001). In a regression analysis, favorable outcome was independently associated with lower-presentation NIHSS (OR, 0.84; 95% CI, 0.76-0.93; P < .001), successful reperfusion (modified TICI score 2b-3; OR, 4.95; 95% CI, 1.18-20.72; P = .03), and favorable VO (OR, 12.35; 95% CI, 4.23-36.10; P < .001).
CONCLUSIONS: In Patients with AIS-LVO treated with EVT that involved ≥3 passes, lower presentation NIHSS, successful reperfusion, and favorable VO were associated with an increased likelihood of a favorable outcome.
PMID:41633799 | DOI:10.3174/ajnr.A9066