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Original research
Impact of time to endovascular reperfusion on outcome differs according to the involvement of the proximal MCA territory
  1. Dennis M Hedderich1,
  2. Tobias Boeckh-Behrens1,
  3. Benjamin Friedrich1,
  4. Benedikt Wiestler1,
  5. Silke Wunderlich2,
  6. Claus Zimmer1,
  7. Urs Fischer3,
  8. Justus F Kleine1,4,
  9. Johannes Kaesmacher1,3
  1. 1Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
  2. 2Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
  3. 3Department of Neurology, Inselspital, University Hostpital Bern and University of Bern, Bern, Switzerland
  4. 4Department of Neuroradiology, Charité, Berlin, Berlin, Germany
  1. Correspondence to Dr Dennis M Hedderich, Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 Munich, Germany; dennis.hedderich{at}


Background The time interval between symptom onset and reperfusion is a major determinant of the benefit of endovascular therapy (ET) and patients’ outcome. The impact of time may be attenuated in patients with robust collaterals. However, not all regions in the middle cerebral artery (MCA) territory have access to collaterals.

Purpose To evaluate if the involvement of the poorly collateralized proximal MCA territory has an impact on the degree of time dependency of patients’ outcome.

Methods Patients with MCA occlusions treated with ET and involvement/sparing of the proximal striatocapsular MCA territory (SC+/SC−, each n=97) were matched according to their symptom onset to reperfusion times (SORTs). Correlation and impact of time on outcome was evaluated with strata of SC+/SC− using multivariate logistic regression models (LRMs), including interaction terms. Discharge National Institute of Health Stroke Scale (NIHSS-DIS) score <5 and discharge modified Rankin Scale (mRS-DIS) score ≤2 were prespecified outcome measures.

Results A stronger correlation between all outcome measures (NIHSS-DIS/ΔNIHSS/mRS-DIS) and SORTs was found for SC+ patients than for SC−patients. SORTs were significant variables in LRMs for mRS-DIS score ≤2 and NIHSS-DIS score <5 in SC+ but not in SC− patients. Interaction of SC+ and SORTs was significant in LRMs for both endpoints.

Conclusion Time dependency of outcome after ET is more pronounced if parts of the proximal MCA territory are affected. This may reflect the lack of collateralization in the striatocapsular region and a more stringent cell death with time. If confirmed, this finding may affect the selection of patients based on different time windows according to the territory at risk.

  • stroke
  • striatocapsular infarcts
  • time
  • collateral
  • thrombectomy

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  • Contributors DMH, JK, and JFK designed the study. DMH and JK wrote the manuscript draft. DMH, JK, JFK, BF, BW, and TB-B analyzed the data. SW, CZ, UF, JK, JFK, BF, BW, and TB-B critically revised the data analysis and the manuscript draft.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests UF receives research grants from the Swiss National Science Foundation (SNSF), serves as a consultant for Medtronic, and is the global principal investigator of the SWIFT DIRECT study.

  • Ethics approval Ethics committee, Technical University of Munich.

  • Provenance and peer review Not commissioned; externally peer reviewed.