Infarcts in a New Territory: Insights From the ESCAPE-NA1 Trial

Research output: Contribution to journalResearch articleContributedpeer-review

Contributors

  • ESCAPE-NA1 Trial Investigators - (Author)
  • Department of Neurology
  • Dresden Neurovascular Center
  • Emory University
  • Brown University
  • Centre Hospitalier de l'Université de Montreal (CHUM)
  • University of Alberta
  • University of British Columbia
  • University of Ottawa
  • McMaster University
  • University of Toronto
  • Erlanger Hospital
  • Baptist Hospital
  • University Hospital Carl Gustav Carus Dresden
  • University of Melbourne
  • NoNO Inc
  • Department of Neurology
  • Dresden Neurovascular Center
  • Alfred Krupp Krankenhaus
  • University of Calgary
  • Foothills Medical Centre

Abstract

BACKGROUND: Infarct in a new territory (INT) is a known complication of endovascular stroke therapy. We assessed the incidence of INT, outcomes after INT, and the impact of concurrent treatments with intravenous thrombolysis and nerinetide.

METHODS: Data are from ESCAPE-NA1 trial (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke), a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in subjects with acute ischemic stroke who underwent endovascular thrombectomy within 12 hours from onset. Concurrent treatment and outcomes were collected as part of the trial protocol. INTs were identified on core lab imaging review of follow-up brain imaging and defined by the presence of infarct in a new vascular territory, outside the baseline target occlusion(s) on follow-up brain imaging (computed tomography or magnetic resonance imaging). INTs were classified by maximum diameter (<2, 2-20, and >20 mm), number, and location. The association between INT and clinical outcomes (modified Rankin Scale and death) was assessed using standard descriptive techniques and adjusted estimates of effect were derived from Poisson regression models.

RESULTS: Among 1092 patients, 103 had INT (9.3%, median age 69.5 years, 49.5% females). There were no differences in baseline characteristics between those with versus without INT. Most INTs (91/103, 88.3%) were not associated with visible occlusions on angiography and 39 out of 103 (37.8%) were >20 mm in maximal diameter. The most common INT territory was the anterior cerebral artery (27.8%). Almost half of the INTs were multiple (46 subjects, 43.5%, range, 2-12). INT was associated with poorer outcomes as compared to no INT on the primary outcome of modified Rankin Scale score of 0 to 2 at 90 days (adjusted risk ratio, 0.71 [95% CI, 0.57-0.89]). Infarct volume in those with INT was greater by a median of 21 cc compared with those without, and there was a greater risk of death as compared to patients with no INT (adjusted risk ratio, 2.15 [95% CI, 1.48-3.13]).

CONCLUSIONS: Infarcts in a new territory are common in individuals undergoing endovascular thrombectomy for acute ischemic stroke and are associated with poorer outcomes. Optimal therapeutic approaches, including technical strategies, to reduce INT represent a new target for incremental quality improvement of endovascular thrombectomy.

REGISTRATION: URL: https://www.

CLINICALTRIALS: gov; Unique identifier: NCT02930018.

Details

Original languageEnglish
Pages (from-to)1477-1483
Number of pages7
JournalStroke
Volume54
Issue number6
Publication statusPublished - Jun 2023
Peer-reviewedYes

External IDs

Scopus 85160200514

Keywords

Keywords

  • Female, Humans, Aged, Male, Ischemic Stroke/complications, Treatment Outcome, Stroke/diagnostic imaging, Brain Ischemia/diagnostic imaging, Thrombectomy/methods, Infarction, Endovascular Procedures/adverse effects