DEFUSE 2 Interventional Procedures Vascular Imaging Evaluation

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DEFUSE 2 Interventional Procedures Vascular Imaging Evaluation

Correlation of TICI Reperfusion with

MR Reperfusion, Infarct Growth and

Clinical Outcome in the DEFUSE 2

Trial

Michael P Marks, MD

On behalf of the DEFUSE 2 investigators


Background

• Assessment of reperfusion based on perfusion

weighted MRI (PWI reperfusion) has been used

more commonly in patients treated with

intravenous thrombolysis.

• The Thrombolysis In Cerebral Infarction (TICI)

score is a widely used angiographic score in

endovascular stroke studies.


Purpose

• This analysis was undertaken to:

1) determine the association between TICI

score and PWI reperfusion &

2) assess the association between TICI

score and clinical and imaging outcomes

Using the DEFUSE 2 study data.


DEFUSE 2

• Multi-center prospective cohort study

• 9 study sites

NIH

Austria

Seattle

Utah

Stanford

Northwestern

Hawaii

Pittsburgh

Portland


DEFUSE 2 acute endovascular Rx

MRI

Baseline

Within 90 min

of anterior circulation strokes

Endovasc

Therapy

Within 12 hrs

MRI

Post-Rx

(reperfusion)

Clinical Assessment

day 30

(NIHSS and Rankin)

MRI 5 d

(infarct volume)


Methods

• Target Mismatch (TMM) was defined as PWI

(Tmax>6s) volume/DWI volume >1.8 [when DWI

10s) was < 100 ml]

• Infarct growth was defined as the difference

between baseline DWI and 5-day FLAIR lesion

volume.


Methods

• PWI-reperfusion was defined as a reduction in

PWI (Tmax>6s) lesion volume of >50% between

baseline and immediate follow-up.


Methods

• Only patients with a TICI score of 0,1 on

baseline DSA were included. A single blinded

reader at the core imaging facility determined

pre- and post-procedure TICI scores.

• TICI-reperfusion was defined as a TICI score of

2B/3.


Grade

0 No perfusion

1

2a

2b

TICI Reperfusion

Perfusion past the initial obstruction, but little or

slow distal perfusion with limited branch filling

Partial perfusion of < ½ of the vascular

distribution of the occluded artery

Partial perfusion of > ½ of the vascular

distribution of the occluded artery

3 Full perfusion with filling of all distal branches


110 patients enrolled

6 technically inadequate baseline PWI,

5 no stroke or v. small PWI

99 patients had baseline PWI & went to cath lab

17 no AOL seen or treated

82 patients had Rx & were TICI 0,1 at baseline DSA

77 had final TICI score at core lab

66 had immediate F/U PWI

5 incomplete data sent to core lab


Final TICI Score

• TICI 0,1- 23 patients (30%)

• TICI 2a- 24 patients (31%)

• TICI 2b- 19 patients (25%)

• TICI 3- 11 patients (14%)

Total 77 patients (100%)

30%

70%


Final TICI Score

• TICI 0,1- 23 patients (30%)

• TICI 2a- 24 patients (31%)

• TICI 2b- 19 patients (25%)

• TICI 3- 11 patients (14%)

Total 77 patients (100%)

61%

39%


Final DSA TICI and PWI Reperfusion*

Percent with PWI Reperfusion

39%

P=0.002

60%

83%

100%

TICI 0-1 TICI 2a TICI 2b TICI 3

* reduction in PWI (Tmax>6s) volume of >50% between baseline and immediate follow-up


Final TICI and Percent Reperfusion

N= 11 7 20 18 10

p


Percent with FCR

70

60

50

40

30

20

10

0

Final TICI and FCR*

P=0.035 P=0.015 P=1.0

20/30

67%

19/47

40% 12/35

34%

16/23

70%

7/12

58%

4/7

57%

Entire Group Target MM No Target MM

TICI 0-2a TICI 2b-3

* NIHSS score of 0-1 or an improvement in NIHSS score of ≥8 points at day 30


Final TICI and 30 Day mRs


Final TICI and Lesion Growth

68

42

N= 37 27

p=0.005


Lesion Growth and TICI

N= 27 20

p=0.002

67

TMM No TMM

11

N= 10 7

p=0.417

128

82


Conclusions

• TICI reperfusion following endovascular therapy

for acute anterior circulation stroke is highly

correlated with PWI reperfusion.

• Patients with TICI 2B-3 reperfusion are more

likely to have good outcome and show less

infarct growth compared with TICI 0-2A.

• These differences were seen in those patients

with TMM and not in patients with No TMM.

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