Imaging Biomarkers for Intra-arterial Stroke Therapy
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Imaging Biomarkers for Intra-arterial Stroke Therapy OLVERT A. BERKHEMER,1,2,3 SHERVIN KAMALIAN,1,2 R. GILBERTO GONZA´LEZ,1,2 CHARLES B. L. M. MAJOIE,3 and ALBERT J. YOO1,2 1
Division of Diagnostic and Interventional Neuroradiology, Department of Imaging, Massachusetts General Hospital, 55 Fruit Street GRB 241, Boston, MA 02114, USA; 2Harvard Medical School, Boston, MA, USA; and 3Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (Received 18 March 2013; accepted 23 April 2013) Associate Editor Ajit P. Yoganathan oversaw the review of this article.
Abstract—Despite high rates of early revascularization with intra-arterial stroke therapy, the clinical efficacy of this approach has not been clearly demonstrated. Neuroimaging biomarkers will be useful in future trials for patient selection and for outcomes evaluation. To identify patients who are likely to benefit from intra-arterial therapy, the combination of vessel imaging, infarct size quantification and degree of neurologic deficit appears critical. Perfusion imaging may be useful in specific circumstances, but requires further validation. For measuring treatment outcomes, surrogate biomarkers that appear suitable are angiographic reperfusion as measured by the modified Thrombolysis in Cerebral Infarction scale and final infarct volume. Keywords—Acute ischemic stroke, CT, Intra-arterial, Endovascular, MRI, Neuroimaging, Reperfusion therapy.
INTRODUCTION In acute ischemic stroke patients, early revascularization is the only proven beneficial therapy.31,82 Intraarterial treatment (IAT) improves revascularization of proximal artery occlusions compared to intravenous tissue plasminogen activator (IV tPA).10 Despite this fact, three recent randomized controlled trials (RCTs) have shown equivalent clinical outcomes between intervention and standard medical management.13,21,46 In this context, neuroimaging biomarkers may play a critical role in future studies. This article will discuss the utility of neuroimaging for enhancing patient selection and improving outcome evaluation.
Address correspondence to Albert J. Yoo, Division of Diagnostic and Interventional Neuroradiology, Department of Imaging, Massachusetts General Hospital, 55 Fruit Street GRB 241, Boston, MA 02114, USA. Electronic mail: [email protected]
NEUROIMAGING BIOMARKERS FOR PREDICTING THE CLINICAL RESPONSE TO INTRA-ARTERIAL TREATMENT Is Advanced Neuroimaging Worth the Time Expense? The chance of a good outcome after IAT decreases with longer time from stroke onset to revascularization.45 Data from the recent Interventional Management of Stroke (IMS) III trial (Table 1) reveal a 10% relative reduction in the probability of good outcome [90-day modified Rankin Scale (mRS) score 0–2] for every 30-min delay in reperfusion, after adjusting for other predictors (Dr. Pooja Khatri, 2013 International Stroke Conference presentation). This has placed an emphasis on rapid treatment, leading some physicians to forego advanced neuroimaging due to fear of treatmen
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