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Ischemic stroke
Original research
Predictors and clinical impact of infarct progression rate in the ESCAPE-NA1 trial
  1. Johanna Maria Ospel1,2,
  2. Rosalie McDonough3,4,
  3. Andrew M Demchuk3,
  4. Bijoy K Menon5,
  5. Mohammed A Almekhlafi6,
  6. Raul G Nogueira7,
  7. Ryan A McTaggart8,
  8. Alexandre Y Poppe9,
  9. Brian H Buck10,
  10. Daniel Roy11,
  11. Diogo C Haussen12,
  12. René Chapot13,
  13. Thalia S Field14,
  14. Mahesh V Jayaraman15,
  15. Michael Tymianski16,
  16. Michael D Hill3,17,
  17. Mayank Goyal18
  18. the ESCAPE-NA1 investigators
  1. 1 Department of Radiology, Universitatsspital Basel, Basel, Switzerland
  2. 2 Department of Diagnostic Imaging, Foothills Medical Centre, Calgary, Alberta, Canada
  3. 3 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  4. 4 Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
  5. 5 Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
  6. 6 Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  7. 7 Departments of Radiology, Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
  8. 8 Faculty of Medicine, Brown University, Providence, Rhode Island, USA
  9. 9 Department of Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
  10. 10 Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
  11. 11 Faculty of Medicine, University de Montreal, Montreal, Quebec, Canada
  12. 12 Department of Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  13. 13 Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
  14. 14 Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
  15. 15 Department of Diagnostic Imaging, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
  16. 16 NoNO Inc, NoNO Inc, Toronto, Ontario, Canada
  17. 17 Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
  18. 18 Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Mayank Goyal, Department of Diagnostic Imaging, University of Calgary, Calgary, Canada; mgoyal2412{at}gmail.com

Abstract

Background Determining infarct progression rate in acute ischemic stroke (AIS) is important for patient triage, treatment decision-making, and outcome prognostication.

Objective To estimate infarct progression rate in patients with AIS with large vessel occlusion (LVO) and determine its predictors and impact on clinical outcome.

Methods Data are from the ESCAPE-NA1 Trial. Patients with AIS with time from last known well to randomization <6 hours and near-complete reperfusion following endovascular treatment were included. Infarct growth rate (mL/h) was estimated by dividing 24 hour infarct volume (measured by non-contrast CT or diffusion-weighted magnetic resonance imaging) by time from last known well to reperfusion. Multivariable linear regression was used to assess the association of patient baseline variables with log-transformed infarct progression rate. The association of infarct progression rate and good outcome (modified Rankin Scale score 0–2) was determined using multivariable logistic regression.

Results Four hundred and nine patients were included in the study. Median infarct progression rate was 4.74 mL/h (IQR 1.25–14.84). Collateral status (β: −0.81 (95% CI −1.20 to −0.41)), Alberta Stroke Program Early CT Score (ASPECTS, β: −0.34 (95% CI −0.46 to −0.23)), blood glucose(β: 0.09 (95% CI 0.02 to 0.16)), and National Institutes of Health Stroke Scale (NIHS score (β: 0.07 (95% CI 0.04 to 0.10)) were associated with log-transformed infarct progression rate. Clinical and imaging baseline variables explained 23% of the variance in infarct progression rate. Infarct progression rate was significantly associated with good outcome (aOR per 1 mL/h increase: 0.96 (95% CI 0.95 to 0.98)).

Conclusion In this sample of patients presenting within the early time window with LVO and near-complete recanalization, infarct progression rate was significantly associated with good outcome. A significant association between ASPECTS, collateral status, blood glucose, and NIHSS score was observed, but baseline imaging and clinical characteristics explained only a small proportion of the interindividual variance. More research on measurable factors affecting infarct growth is needed.

  • stroke
  • thrombectomy
  • CT
  • CT angiography

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The data underlying this research will be made available by the corresponding author upon reasonable request and after approval by the ESCAPE-NA1 investigator committee.

https://doi.org/10.1136/neurintsurg-2021-017994

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. The data underlying this research will be made available by the corresponding author upon reasonable request and after approval by the ESCAPE-NA1 investigator committee.

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    Footnotes

    • Twitter @johanna_ospel, @AlmekhlafiMa, @diogohaussen, @mihill68

    • JMO and RM contributed equally.

    • Collaborators the ESCAPE-NA1 investigators.

    • Contributors JMO, RM, MDH, MG: conceptualization, statistical analysis, drafting, and critical revision of the manuscript. All authors: data curation, critical revision of the manuscript.

    • Funding The ESCAPE-NA1 Trial was supported by: Canadian Institutes of Health Research; Alberta Innovates NoNo Inc.

    • Competing interests AMD: stock options and patients (Circle Neurovascular); honoraria for CME events (Boehringer Ingelheim); consultant (Medtronic). AYP: research grant to the institution (Stryker); payment/honoraria for lectures: C-CHANGE education program (update on stroke guidelines for general practitioners); participation on a data safety monitoring board or advisory board (FLOW trial); chair, Canadian Stroke Consortium National Stroke Fellowship Program. RGN: grant to Emory University (Cerenovus); consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron; consulting fees for medical legal consultations; stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, and Perfuze; investor in Viz-AI, Perfuze, Cerebrotech, Reist LLC, Truvic, and Viseon. MVJ: treasurer, Society of Neurointerventional Surgery 2019–2021; vice president, Society of Neurointerventional Surgery 2021–present. MDH: grants to the University of Calgary for ESCAPE-NA1 (NoNO Inc); grants to the University of Calgary for ESCAPE-NA1 (CIHR); grants to the University of Calgary for ESCAPE-NA1 and the QuICR Alberta Stroke Program (Alberta Innovates); grants to the University of Calgary for TEMPO 2 (Boehringer Ingelheim); grants to the University of Calgary (Biogen); paid work for adjudication of clinical trial outcomes (Sun Pharma), US patent 62/086,077 and 10,916,346 (licensed to Circle Neurovascular); DSMC Chair (RACECAT, Oncovir Hiltonel, DUMAS Trials); DSMB member (ARTESIA, BRAIN-AF trials); president Canadian Neurological Sciences Federation (not for profit); board member founder and part ownership (Circle Neurovascular). MT: NoNO Inc. shareholder; president and CEO of NoNO Inc., owns patent for Nerinetide/NA1. MG: honoraria from Medtronic, Microvention, Mentice, and Stryker (teaching and advice on acute stroke intervention); ESCAPE-NA1 was funded through a grant to the University of Calgary from NoNO Inc.

    • 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.