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Hypoperfusion intensity ratio for refinement of elderly patient selection for endovascular thrombectomy
  1. Andre Monteiro1,
  2. Gustavo M Cortez1,2,
  3. Elena Greco1,
  4. Amin Aghaebrahim1,
  5. Eric Sauvageau1,
  6. Ricardo A Hanel1
  1. 1 Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
  2. 2 Research Department, Jacksonville University, Jacksonville, FL, USA
  1. Correspondence to Dr Ricardo A Hanel, Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL 32207-8202, USA; rhanel{at}


Background Patients ≥80-year-old presenting with large-vessel occlusion treated with endovascular thrombectomy (EVT) have worst outcomes than younger individuals. Improved patient selection in this age range is warranted. We investigated the hypoperfusion-intensity-ratio (HIR) and its associations with baseline parameters and clinical outcomes in a cohort ≥80-year-old to assess whether it could an option in improving their selection for EVT.

Methods We performed retrospective analysis of consecutive patients treated with EVT at our center between 2015 and 2019. Inclusion criteria were age ≥80-year-old, any baseline modified Rankin Scale (mRS), and anterior circulation occlusion. Demographic information, baseline characteristics, clinical data, and radiological imaging parameters were collected. HIR was dichotomized into favorable and unfavorable based on median value of the cohort. Good outcome was defined as mRS ≤2 at 90-days.

Results We included 82 patients. HIR was significantly correlated with baseline ischemic core volume, NIHSS, and time-of-onset to groin puncture. Good outcome was achieved in 18.3% and mortality occurred in 34.1%. In patients with baseline mRS ≤2, the rate of good outcome was significantly higher in favorable vs unfavorable HIR (52.6% vs 20%, P=0.02). In shift-analysis, unfavorable HIR was significantly associated with downshift to mRS ≥3 (P=0.02). Regression analysis found lower baseline mRS (P=0.009), higher ASPECTS (P=0.02), complete recanalization (P=0.04), and lower HIR (P=0.02) to be associated with increased rate of good outcome. Hierarchical regression showed HIR to independently predict good outcome.

Conclusions In our cohort, HIR was correlated with baseline parameters and predicted clinical outcomes. Future studies should investigate perfusion parameters such as HIR to improve the selection of elderly patients for EVT.

  • CT perfusion
  • stroke
  • thrombectomy

Data availability statement

Data are available upon reasonable request. Data are available upon a reasonable request.

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Data availability statement

Data are available upon reasonable request. Data are available upon a reasonable request.

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  • Contributors AM contributed with original idea, data collection, analysis, and manuscript writing. GM performed data collection and revision of the analysis. EG participated in data collection. AA and ES contributed with orientation and revision throughout manuscript writing. RH contributed with guidance through the original idea, orientation during manuscript writing, and revision of final work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests RAH reports conflict of interest with Medtronic, Cerenovous, Balt, and Phenox, and is a stockholder for Neurvana, Elum, Endostream, Three Rivers Medical Inc., Synchron, Deinde, Rist, Cerebrotech Medical Systems Inc., InNeurCo, Serenity, Scientia, BendIT, and Blink TBI. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices involved in the study.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.