Infarct in a New Territory After Treatment Administration in the ESCAPE Randomized Controlled Trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times).

Stroke 2016 12 10;47(12):2993-2998. Epub 2016 Nov 10.

From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital, Ontario, Canada; Departments of Radiology (J.L.R.) and Medicine (Neurology) (K.B.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J. Thornton) and Geriatric and Stroke Medicine (P.K.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), CHUM, University of Montreal, Quebec, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services (T.D.) and Department of Radiology, Erlanger Hospital (B.W.B.), University of Tennessee, Chattanooga; Colorado Neurological Institute, Englewood (D.F.F.); Department of Neurointerventional Care, The Neurosciences Institute, Abington Memorial Hospital, Abington, PA (H.C.); Department of Diagnostic and Interventional Neuroradiology (D.T.) and Department of Neurology and Neurosurgery (J. Teitelbaum), Montreal Neurological Institute, McGill University, Quebec, Canada; Department of Radiology, The Ottawa Hospital, University of Ottawa, Ontario, Canada (C.L.); Department of Clinical Neurological Sciences, London Health Sciences Center, Western University, Ontario, Canada (J.M.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (S.J.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (O.Y.B.); Department of Neurology, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.M.); and the Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (A.G.).

Background And Purpose: Infarct in a new previously unaffected territory (INT) is a potential complication of endovascular treatment. We applied a recently proposed methodology to identify and classify INTs in the ESCAPE randomized controlled trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times).

Methods: The core laboratory identified INTs on 24-hour follow-up imaging, blinded to treatment allocation, after assessing all baseline imaging. INTs were classified into 3 types (I-III) and 2 subtypes (A/B) based on size and if catheter manipulation was likely performed across the vessel territory ostium. Logistic regression was used to understand the effect of multiple a priori identified variables on INT occurrence. Ordinal logistic regression was used to analyze the effect of INTs on modified Rankin Scale shift at 90 days.

Results: From 308 patients included, 14 INTs (4.5% overall; 2.8% on follow-up noncontrast computed tomography, 11.7% on follow-up magnetic resonance imaging) were identified (5.0% in endovascular treatment arm versus 4.0% in control arm [P=0.7]). The use of intravenous alteplase was associated with a 68% reduction in the odds of INT occurrence (3.0% with versus 9.1% without; odds ratio, 0.32; 95% confidence interval, 0.11-0.96; adjusted for age, sex, and treatment type). No other variables were associated with INTs. INT occurrence was associated with reduced probability of good clinical outcome (common odds ratio, 0.25; 95% confidence interval, 0.09-0.74; adjusted for age, type of treatment, and follow-up scan).

Conclusions: INTs are uncommon, detected more frequently on follow-up magnetic resonance imaging, and affect clinical outcome. In experienced centers, endovascular treatment is likely not causal, whereas intravenous alteplase may be therapeutic.

Clinical Trial Registration: URL: Unique identifier: NCT01778335.

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