Infarct in a New Territory After Treatment Administration in the ESCAPE Randomized Controlled Trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)

Aravind Ganesh; Fahad S Al-Ajlan; Farahna Sabiq; Zarina Assis; Jeremy L Rempel; Kenneth Butcher; John Thornton; Peter Kelly; Daniel Roy; Alexandre Y Poppe; Tudor G Jovin; Thomas Devlin; Blaise W Baxter; Timo Krings; Leanne K Casaubon; Donald F Frei; Hana Choe; Donatella Tampieri; Jeanne Teitelbaum; Cheemun Lum; Jennifer Mandzia; Stephen J Phillips; Oh Young Bang; Mohammed A Almekhlafi; Shelagh B Coutts; Philip A Barber; Tolulope Sajobi; Andrew M Demchuk; Muneer Eesa; Michael D Hill; Mayank Goyal; Bijoy K Menon; ESCAPE Trial Investigators

doi:10.1161/STROKEAHA.116.014852

Infarct in a New Territory After Treatment Administration in the ESCAPE Randomized Controlled Trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)

Stroke. 2016 Dec;47(12):2993-2998. doi: 10.1161/STROKEAHA.116.014852. Epub 2016 Nov 10.

Authors

Aravind Ganesh¹, Fahad S Al-Ajlan¹, Farahna Sabiq¹, Zarina Assis¹, Jeremy L Rempel¹, Kenneth Butcher¹, John Thornton¹, Peter Kelly¹, Daniel Roy¹, Alexandre Y Poppe¹, Tudor G Jovin¹, Thomas Devlin¹, Blaise W Baxter¹, Timo Krings¹, Leanne K Casaubon¹, Donald F Frei¹, Hana Choe¹, Donatella Tampieri¹, Jeanne Teitelbaum¹, Cheemun Lum¹, Jennifer Mandzia¹, Stephen J Phillips¹, Oh Young Bang¹, Mohammed A Almekhlafi¹, Shelagh B Coutts¹, Philip A Barber¹, Tolulope Sajobi¹, Andrew M Demchuk¹, Muneer Eesa¹, Michael D Hill¹, Mayank Goyal¹, Bijoy K Menon²; ESCAPE Trial Investigators

Affiliations

¹ From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital, Ontario, Canada; Departments of Radiology (J.L.R.) and Medicine (Neurology) (K.B.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J. Thornton) and Geriatric and Stroke Medicine (P.K.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), CHUM, University of Montreal, Quebec, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services (T.D.) and Department of Radiology, Erlanger Hospital (B.W.B.), University of Tennessee, Chattanooga; Colorado Neurological Institute, Englewood (D.F.F.); Department of Neurointerventional Care, The Neurosciences Institute, Abington Memorial Hospital, Abington, PA (H.C.); Department of Diagnostic and Interventional Neuroradiology (D.T.) and Department of Neurology and Neurosurgery (J. Teitelbaum), Montreal Neurological Institute, McGill University, Quebec, Canada; Department of Radiology, The Ottawa Hospital, University of Ottawa, Ontario, Canada (C.L.); Department of Clinical Neurological Sciences, London Health Sciences Center, Western University, Ontario, Canada (J.M.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (S.J.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (O.Y.B.); Department of Neurology, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.M.); and the Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (A.G.).
² From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital, Ontario, Canada; Departments of Radiology (J.L.R.) and Medicine (Neurology) (K.B.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J. Thornton) and Geriatric and Stroke Medicine (P.K.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), CHUM, University of Montreal, Quebec, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services (T.D.) and Department of Radiology, Erlanger Hospital (B.W.B.), University of Tennessee, Chattanooga; Colorado Neurological Institute, Englewood (D.F.F.); Department of Neurointerventional Care, The Neurosciences Institute, Abington Memorial Hospital, Abington, PA (H.C.); Department of Diagnostic and Interventional Neuroradiology (D.T.) and Department of Neurology and Neurosurgery (J. Teitelbaum), Montreal Neurological Institute, McGill University, Quebec, Canada; Department of Radiology, The Ottawa Hospital, University of Ottawa, Ontario, Canada (C.L.); Department of Clinical Neurological Sciences, London Health Sciences Center, Western University, Ontario, Canada (J.M.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (S.J.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (O.Y.B.); Department of Neurology, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.M.); and the Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (A.G.). docbijoymenon@gmail.com.

PMID: 27834743
DOI: 10.1161/STROKEAHA.116.014852

Abstract

Background and purpose: Infarct in a new previously unaffected territory (INT) is a potential complication of endovascular treatment. We applied a recently proposed methodology to identify and classify INTs in the ESCAPE randomized controlled trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times).

Methods: The core laboratory identified INTs on 24-hour follow-up imaging, blinded to treatment allocation, after assessing all baseline imaging. INTs were classified into 3 types (I-III) and 2 subtypes (A/B) based on size and if catheter manipulation was likely performed across the vessel territory ostium. Logistic regression was used to understand the effect of multiple a priori identified variables on INT occurrence. Ordinal logistic regression was used to analyze the effect of INTs on modified Rankin Scale shift at 90 days.

Results: From 308 patients included, 14 INTs (4.5% overall; 2.8% on follow-up noncontrast computed tomography, 11.7% on follow-up magnetic resonance imaging) were identified (5.0% in endovascular treatment arm versus 4.0% in control arm [P=0.7]). The use of intravenous alteplase was associated with a 68% reduction in the odds of INT occurrence (3.0% with versus 9.1% without; odds ratio, 0.32; 95% confidence interval, 0.11-0.96; adjusted for age, sex, and treatment type). No other variables were associated with INTs. INT occurrence was associated with reduced probability of good clinical outcome (common odds ratio, 0.25; 95% confidence interval, 0.09-0.74; adjusted for age, type of treatment, and follow-up scan).

Conclusions: INTs are uncommon, detected more frequently on follow-up magnetic resonance imaging, and affect clinical outcome. In experienced centers, endovascular treatment is likely not causal, whereas intravenous alteplase may be therapeutic.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.

Keywords: cerebral infarction; clinical protocols; follow-up studies; magnetic resonance imaging; plasminogen activator; tissue-type.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Cerebral Infarction / classification
Cerebral Infarction / diagnostic imaging*
Cerebral Infarction / therapy*
Fibrinolytic Agents / adverse effects
Fibrinolytic Agents / therapeutic use*
Humans
Thrombolytic Therapy / adverse effects
Thrombolytic Therapy / methods*
Tissue Plasminogen Activator / adverse effects
Tissue Plasminogen Activator / therapeutic use*

Substances

Fibrinolytic Agents
Tissue Plasminogen Activator

Associated data

ClinicalTrials.gov/NCT01778335