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• W2945551818 abstract "HomeStrokeVol. 50, No. 6Response by Guenego and Heit to Letter Regarding Article, “Hypoperfusion Intensity Ratio Is Correlated With Patient Eligibility for Thrombectomy” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Guenego and Heit to Letter Regarding Article, “Hypoperfusion Intensity Ratio Is Correlated With Patient Eligibility for Thrombectomy” Adrien Guenego, MD and Jeremy J. Heit, MD, PhD Adrien GuenegoAdrien Guenego Interventional and Diagnostic Neuroradiology, Stanford Medical Center, CA Search for more papers by this author and Jeremy J. HeitJeremy J. Heit Interventional and Diagnostic Neuroradiology, Stanford Medical Center, CA Search for more papers by this author Originally published14 May 2019https://doi.org/10.1161/STROKEAHA.119.025863Stroke. 2019;50:e174Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 14, 2019: Ahead of Print In Response:We thank Wu et al for their letter in response to our article in Stroke entitled “Hypoperfusion Intensity Ratio Is Correlated With Patient Eligibility for Thrombectomy.”1 We welcome the opportunity to respond to their comments about our study.Wu et al note that imaging variables for stroke patient triage should be combined with other parameters such as time from symptom onset to imaging and neurological deficit. We would like to point out that these variables were considered in our article (see Table 1), and we certainly agree that the clinical evaluation of a patient before consideration of thrombectomy is essential. In our study, hypoperfusion intensity ratio (HIR) was investigated as an imaging biomarker for thrombectomy eligibility in a retrospective manner. Therefore, HIR was not used for making treatment decisions in our study. We plan to investigate the prospective use of HIR for thrombectomy triage in future studies.With respect to their statement that a combination of a neurological deficit, angiographic confirmation of a large vessel occlusion, and favorable Alberta Stroke Program Early CT Score (ASPECTS) are sufficient for mechanical thrombectomy treatment in late time windows, we would caution that this approach lacks validation in large, randomized clinical trials. The late window DEFUSE 32 (Endovascular Therapy Following Imaging Valuation for Ischemic Stroke) study excluded patients with low ASPECTS (<6), and the DAWN3 (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention) trial did not use ASPECTS in its enrollment criteria. Core infarct volume was determined in both DEFUSE 3 and DAWN by computed tomography perfusion or diffusion-weighted imaging magnetic resonance imaging. DEFUSE 3 further used perfusion imaging to identify patients with a target mismatch between the volume of core infarction and salvageable penumbra for enrollment. Therefore, ASPECTS to estimate core infarction has not been directly studied in the context of late window randomized trials, and we look forward to such studies that advance our knowledge about the utility of ASPECTS in late window stroke patient triage. At this time, the evidence from retrospective studies is insufficient to recommend the use of ASPECTS as the primary means of patient triage in late time windows.In response to Wu et al’s concern about the optimal HIR threshold, they are correct that we did not seek to determine a different HIR threshold in our study. The HIR 0.4 threshold was derived from prospectively acquired data in the DEFUSE 2 study,4 which we have used in other studies as well.5 Interestingly, when all patients in our study were considered, the median HIR was 0.4 (interquartile range, 0.3–0.6), and our results also suggest that this is a reasonable threshold.Last, Wu et al raised concerns that the perfusion imaging evaluation used in our study was not suitable for the triage of patients beyond 16 hours given that DEFUSE 3 did not enroll patients between 16 and 24 hours. As we stated in the methods, the only late window patients included in the analysis met inclusion criteria for DEFUSE 3, and there were no patients who presented beyond 16 hours in our study.We do look forward to future studies designed to determine the utility of perfusion imaging and HIR in even later time windows in the future. There is also a further need for prospective studies to verify our results and determine if collaterals assessment by HIR at primary stroke centers before transfer to a comprehensive stroke center is a meaningful measure of mechanical thrombectomy treatment eligibility, as stated in our conclusion.AdrienGuenego, MDJeremy J. Heit, MD, PhDInterventional and Diagnostic NeuroradiologyStanford Medical CenterCADisclosuresDr Heit is a consultant for Medtronic and MicroVention and a member of the medical and scientific advisory board for iSchemaView. The other author reports no conflicts.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 4 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.Guest Editor for this article was Michael Brainin, MD Dr (hon), FESO, FAHA.References1. Guenego A, Marcellus DG, Martin BW, Christensen S, Albers GW, Lansberg MG, et al. Hypoperfusion intensity ratio is correlated with patient eligibility for thrombectomy.Stroke. 2019; 50:917–922. doi: 10.1161/STROKEAHA.118.024134LinkGoogle Scholar2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378:708–718. doi: 10.1056/NEJMoa1713973CrossrefMedlineGoogle Scholar3. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.N Engl J Med. 2018; 378:11–21. doi: 10.1056/NEJMoa1706442CrossrefMedlineGoogle Scholar4. Olivot JM, Mlynash M, Inoue M, Marks MP, Wheeler HM, Kemp S, et al; DEFUSE 2 Investigators. Hypoperfusion intensity ratio predicts infarct progression and functional outcome in the DEFUSE 2 Cohort.Stroke. 2014; 45:1018–1023. doi: 10.1161/STROKEAHA.113.003857LinkGoogle Scholar5. Guenego A, Mlynash M, Christensen S, Kemp S, Heit JJ, Lansberg MG, et al. Hypoperfusion ratio predicts infarct growth during transfer for thrombectomy.Ann Neurol. 2018; 84:616–620. doi: 10.1002/ana.25320CrossrefGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails June 2019Vol 50, Issue 6 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.119.025863PMID: 31084321 Originally publishedMay 14, 2019 PDF download Advertisement SubjectsComputerized Tomography (CT)ImagingIschemic StrokeMagnetic Resonance Imaging (MRI)" @default.
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