Background/Aims
Pivotal endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) based on ischemic core and core-penumbra mismatch were suboptimal in predicting EVT outcomes. Hypothesizing that the perfusion status of eloquent brain regions is more crucial in post-EVT prognostication, we aimed to determine EVT outcomes in patients with critical hypoperfusion in pre-specified eloquent brain regions.
Methods
In this multicentre retrospective study, we retrieved patients with acute middle cerebral artery or internal carotid artery occlusion who received CT perfusion before EVT from 4 hospitals in Hong Kong and mainland China in recent 4 years, excluding patients with angiographic results of mTICI<2b. We automatically generated perfusion profiles for 79 brain regions using a custom-developed pipeline, and assessed the association between the predictor of regional ischemic core to regional hypoperfused area ratio (unit in 10%) and poor functional recovery (mRS>3) using multivariate logistic regression adjusted for ischemic core, ASPECTS, collateral score, and other clinical indicators.
Results
Among 310 identified acute LVO patients, 83 (26.8%) had poor functional recovery despite successful EVT. Multivariate logistic regression revealed the predictor in the primary motor cortex (aOR=1.38, p=0.015), lentiform nucleus (aOR=1.16, p=0.038), internal capsule (aOR=1.23, p=0.029), caudate (aOR=1.17, p=0.018) and the eloquent involvement of these regions (aOR=1.72, p<0.01) were associated with poor functional recovery independent of other control factors. The mean absolute SHapley Additive exPlanations on the eloquent regions show a strong predictive power (SHAP=0.23) to the poor clinical outcome.
Conclusion
The predictive model using the eloquent regions significantly improves the prognostic accuracy of successful EVT.