MR RESCUE
2013; Lippincott Williams & Wilkins; Volume: 44; Issue: 7 Linguagem: Espanhol
10.1161/strokeaha.113.001443
ISSN1524-4628
AutoresMark Parsons, Gregory W. Albers,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoHomeStrokeVol. 44, No. 7MR RESCUE Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBMR RESCUEIs the Glass Half-Full or Half-Empty? Mark W. Parsons, MD, PhD and Gregory W Albers, MD Mark W. ParsonsMark W. Parsons From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia (M.W.P., G.W.A.); and the Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA (M.W.P., G.W.A.). and Gregory W AlbersGregory W Albers From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia (M.W.P., G.W.A.); and the Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA (M.W.P., G.W.A.). Originally published11 Jun 2013https://doi.org/10.1161/STROKEAHA.113.001443Stroke. 2013;44:2055–2057Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 IntroductionThe timely concurrent publication of Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) with the International Management of Stroke Trial III and the Local Versus Systemic Thrombolysis for Acute Ischemic Stroke (SYNTHESIS) Expansion trials confirmed that endovascular therapy was not superior to standard care for patients with acute ischemic stroke.1–3 The novel conclusion from MR RESCUE was that, "…a favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy." Some have interpreted this finding to support a pessimistic (glass half-empty) view of advanced imaging selection for acute reperfusion therapy. We disagree with this viewpoint and argue that the results of MR RESCUE should not dampen enthusiasm for the concept of imaging-based selection. Key limitations of MR RESCUE that hinder the generalizability of the conclusions of the study include enrollment bias, with a preponderance of patients having large infarct cores, and late times to endovascular therapy combined with very low rates of adequate early reperfusion. Lessons learned from this important study should help guide future trials.MR RESCUE was a phase IIb randomized, controlled, open-label, blinded outcome, multicenter study. Patients were assigned within 8 hours after the onset of large-vessel anterior circulation stroke to undergo embolectomy (with the first-generation Merci or Penumbra devices) or standard care (37% of patients received IV recombinant tissue plasminogen activator). Based on MRI (80%) or multimodal computed tomography, randomization was stratified according to whether the patient had a favorable penumbral pattern (infarct core 6 seconds has good specificity for defining tissue at-risk of progressing to infarction for both MR and CT than the thresholds used in MR RESCUE, and this threshold is being used in several ongoing trials.11–13Data regarding the proportion of at-risk tissue that had very severe hypoperfusion (eg, Tmax >10 seconds) were not presented. This may explain the somewhat paradoxical finding that the volumes of at-risk tissue in the nonpenumbral groups were much greater (227 and 231 mL) than the favorable penumbral pattern group. Reperfusion of patients with this Malignant Mismatch pattern is likely to be futile, with infarct growth, possible hemorrhage, and poor clinical outcomes.6,14 Given the large volumes of at-risk tissue in the nonpenumbral MR RESCUE group and the substantial infarct growth seen in this group, we speculate that many of these patients may have had a Malignant Mismatch profile, with large volumes of severe unsalvageable hypoperfusion. MR RESCUE highlights the need to continue the quest to standardize (and simplify) core and salvageable tissue definition with advanced neuroimaging.A Glass Half-FullBecause of the limitations discussed above, we do not feel that the MR RESCUE results should dampen enthusiasm for continued research to refine and improve imaging-based patient selection. The results from multiple previous studies remain highly encouraging and strongly suggest that imaging has the potential to play a key role in optimizing patient selection for stroke therapies.5,12,15,16 Future trials should aim for inclusion of patients with smaller infarct core volumes, faster imaging to reperfusion times, and more effective reperfusion strategies. We believe that the glass remains halffull, but that there is considerable work left to be done. Advanced imaging approaches should continue to be tested in well-designed clinical trials, both within and outside the current therapeutic time window.DisclosuresDr Parsons is recipient of an Australia Research Council Future Fellowship (FT0991128) and an Australian National Health and Medical Research Council Program Grant (ID:1013612); both grants relate to stroke imaging and treatment. Dr Albers has received consulting fees and expenses from Lundbeck and Covidien for steering committee work and consulting fees from Concentric for serving on a data safety and monitoring board. Dr Albers is an equity shareholder in iSchemaView.FootnotesCorrespondence to Mark W. Parsons, MD, PhD, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia. E-mail [email protected]References1. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al; Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke.N Engl J Med. 2013; 368:893–903.CrossrefMedlineGoogle Scholar2. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke.N Engl J Med. 2013; 368:904–913.CrossrefMedlineGoogle Scholar3. 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Refinement of the magnetic resonance diffusion-perfusion mismatch concept for thrombolytic patient selection: insights from the desmoteplase in acute stroke trials.Stroke. 2012; 43:2313–2318.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Xiang X and Cao F (2018) Time window and "tissue window": two approaches to assist decision-making in strokes, Journal of Neurology, 10.1007/s00415-018-8933-5, 266:2, (283-288), Online publication date: 1-Feb-2019. Maniskas M, Roberts J, Trueman R, Learoyd A, Gorman A, Fraser J and Bix G (2016) Intra-arterial nitroglycerin as directed acute treatment in experimental ischemic stroke, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2016-012793, 10:1, (29-33), Online publication date: 1-Jan-2018. 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