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CLEAR LVO

Reperfusion Without Functional Independence in Late Presentation of Stroke With Large Vessel Occlusion

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Year of Publication: 2022

Authors: Fatih Seker, Muhammad M. Qureshi, Markus A. Möhlenbruch, ..., Simon Nagel

Journal: Stroke

Citation: Stroke. 2022;53:3594–3604. doi:10.1161/STROKEAHA.122.039476

Link: https://www.ahajournals.org/doi/10.1161/STROKEAHA.122.039476

Clinical Question

Does the imaging modality used for thrombectomy selection in the extended time window (CT vs CTP vs MRI) impact the rate of reperfusion without functional independence (RFI), symptomatic ICH, or mortality?

Bottom Line

Imaging modality (CT, CTP, MRI) did not influence the likelihood of RFI, sICH, or mortality after thrombectomy in the extended window. Risk was more dependent on age, stroke severity, and prestroke disability.

Major Points

  • Multicenter retrospective analysis of 715 patients with anterior circulation stroke treated with thrombectomy 6–24 hours from last seen well
  • All patients achieved mTICI 2c or 3 reperfusion
  • 50.9% experienced RFI (mRS 3–6 at 90 days)
  • No significant difference in RFI by imaging modality (CT, CTP, MRI)
  • Older age, higher NIHSS, higher prestroke mRS, and longer delay to puncture predicted RFI and mortality
  • Hypertension was associated with symptomatic ICH

Design

Study Type: Multicenter retrospective cohort

Randomization:

Blinding: Unblinded

Enrollment Period: January 2014 – December 2020

Follow-up Duration: 90 days

Centers: 15

Countries: 5

Sample Size: 715

Analysis: Multivariable regression with generalized estimating equations; multiple imputation for missing data; adjusted for age, NIHSS, mRS, comorbidities, occlusion site, ASPECTS, and time metrics

Inclusion Criteria

  • Acute ischemic stroke due to ICA, M1, or M2 occlusion
  • NIHSS ≥6
  • Prestroke mRS 0–2
  • Time-last-seen-well to treatment 6–24 hours
  • Successful reperfusion (mTICI 2c or 3)

Exclusion Criteria

  • mTICI 2b or lower reperfusion
  • Missing 90-day mRS data
  • Missing key covariates (e.g., ASPECTS, IV tPA status)

Arms

FieldControlCTPMRI
InterventionNoncontrast CT ± CTA for thrombectomy selectionCT perfusion including NCCT and CTA for thrombectomy selectionMRI with or without perfusion-weighted imaging for thrombectomy selection
DurationImaging modality used at presentationImaging modality used at presentationImaging modality used at presentation

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Reperfusion without functional independence (mRS 3–6 at 90 days after mTICI 2c/3)Primary50.9% overallNo difference by imaging modalityCTP vs CT p=0.664; MRI vs CT p=0.115
Symptomatic intracranial hemorrhageSecondary5.2% overallNo difference by imaging type2.410.019 (hypertension as risk factor)
90-day mortalitySecondary17.8% overallNo difference by imaging type2.32<0.0001 (transfer), 0.025 (age)
Symptomatic Intracranial HemorrhageAdverse5.2%No difference by imaging2.410.019 (hypertension predictor)

Subgroup Analysis

Older age, higher NIHSS, prestroke mRS ≥1, lower ASPECTS, and ICA/M1 occlusion were associated with worse functional outcomes regardless of imaging modality

Criticisms

  • Retrospective, nonrandomized design
  • Imaging modality choice was site-dependent and not standardized
  • No data on patients not undergoing thrombectomy
  • No core/perfusion imaging parameters included
  • No adjustment for postprocedural variables like infarct size or anesthesia

Funding

Medtronic and the Society of Vascular and Interventional Neurology (SVIN)

Based on: CLEAR LVO (Stroke, 2022)

Authors: Fatih Seker, Muhammad M. Qureshi, Markus A. Möhlenbruch, ..., Simon Nagel

Citation: Stroke. 2022;53:3594–3604. doi:10.1161/STROKEAHA.122.039476

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