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Imaging predictors of procedural and clinical outcome in endovascular acute

stroke therapy

Article  in  Neurovascular Imaging · December 2015

DOI: 10.1186/s40809-015-0004-z

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Telischak and Wintermark Neurovascular Imaging (2015) 1:4
DOI 10.1186/s40809-015-0004-z

REVIEW Open Access

Imaging predictors of procedural and clinical

outcome in endovascular acute stroke therapy
Nicholas A. Telischak* and Max Wintermark

Abstract
Acute stroke affects 795,000 people per year in the United States, and eighty-seven percent of these represent
ischemic stroke. New level I evidence has created a need for consistent, effective and rapid triage of stroke patients
to properly select those who will most benefit from endovascular stroke therapy. This review highlights anatomical
factors and imaging signs that are prognostic with respect to stroke outcome and which could aid in the selection
of patients that could most benefit from interventional stroke therapies, as well as exclude patients from therapy
who are at a high risk of complication.
Keywords: Stroke, Endovascular stroke, Perfusion imaging, Clot characteristics, Blood brain permeability, Core infarct

Introduction these trials have resulted in recent randomized controlled

Acute stroke affects 795,000 people per year in the United trials overwhelmingly favoring endovascular stroke therapy.
States, and eighty-seven percent of these represent ische- Intra-arterial thrombolysis was originally evaluated in
mic stroke. The prevalence of stroke is projected to in- a randomized-controlled trial using the drug pro-
crease 20.5 % by the year 2030, as a result of an aging urokinase in the PROACT II trial, which showed 66 %
population [1]. While intravenous tissue plasminogen acti- recanalization in patients randomized to treatment, but
vator (tPA) has been a mainstay of stroke therapy since its also showed a relatively high rate of symptomatic intra-
approval by the Food and Drug Administration in 1996, cranial hemorrhage. The clinical outcomes showed no
interventional treatment of stroke provides the best pos- difference in mortality between groups, and an absolute
sible chance of a good clinical outcome when patients are increase in favorable outcome of 15 % in the interven-
appropriately selected, as has recently been borne out by a tional group, corresponding to a number needed to treat
handful of randomized controlled trials [2–5]. While this of 7 [6]. The drug used in this trial, urokinase, was
wealth of new data is very exciting, predicting which pa- pulled by the FDA due to “significant deviations from
tients will respond best to stroke therapy remains a chal- Current Good Manufacturing Practices” [7].
lenge. In this review, we aim to highlight imaging findings The IMS III trial randomized 656 participants and
prior to stroke therapy that may predict therapeutic and showed similar rates of functional independence (mRS 0-2)
clinical success. of 40.8 % and 38.7 % in the endovascular and IV tPA
groups, respectively, with a trend toward better outcomes
Clinical trials of endovascular treatment of stroke in the endovascular group among patients with National
Interventional treatment of stroke denotes any catheter- Institute of Health Stroke Scale (NIHSS) >20 [8]. A strong
directed therapy and has progressed from intra-arterial ad- criticism of this trial is that less than half of patients got a
ministration of tPA to mechanical clot disruption with a CTA resulting in 20 % of patients without a large vessel oc-
microwire, the MERCI device, suction thrombectomy (e.g. clusion being randomized to the interventional arm. Stand-
Penumbra), and use of stent-retriever devices including ard dose IV tPA was not given to the majority of patients
Solitaire and TREVO. Initially the IMS III, SYNTHESIS in the interventional arm. Due to the slow trial recruitment,
expansion, and MR RESCUE trials failed to show a clinical there were many protocol iterations with many patients re-
benefit to interventional stroke. Lessons learned from ceiving interventional therapy with first-generation devices
that do not have the same efficacy or safety profile as
* Correspondence: [email protected]
Department of Neuroradiology, S047 300 Pasteur Drive, Stanford, CA 94305, USA

© 2016 Telischak and Wintermark. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 2 of 12

Table 1 Modified Rankin Scale (mRS) for standardized achieved a very low reperfusion rate (27 %) compared with
evaluation of clinical outcome after stroke modern trials [10].
Modified Rankin Clinical Description Many lessons learned from the shortcomings of these
Scale (mRS) trials have highlighted the attributes of an ideal candidate
0 No symptoms. for stroke intervention: 1) A proximal vessel occlusion
1 No significant disability. Able to carry out all that can be reached by an endovascular approach, 2) a
usual activities despite some symptoms. small area of core infarction, and 3) viable tissue at risk of
2 Slight disability. Able to look after own affairs infarction if reperfusion is not achieved, the ischemic
without assistance, but unable to carry out all “penumbra” [11]. This knowledge has resulted in a wealth
previous activities.
of recent trials showing overwhelming benefit of endovas-
3 Moderate disability. Requires some help, but
able to walk unassisted.
cular stroke therapy beginning with the MR CLEAN trial
from the Netherlands.
4 Moderately severe disability. Unable to attend to
own bodily needs without assistance. Unable to MR CLEAN enrolled 500 patients with a confirmed
walk unassisted. proximal arterial occlusion in the anterior cerebral circu-
5 Severe disability. Requires constant nursing care lation who could be treated intra-arterially within 6 h of
and attention, bedridden, incontinent. symptom onset. The majority (89 %) of enrolled patients
6 Dead. were treated with IV-tPA prior to endovascular therapy,
and in the interventional arm four out of five patients
(81.5 %) were treated with retrievable stent devices
today’s stentrievers (40 % recanalization in IMS III versus resulting in a good rate (58.7 %) of recanalization. Using
68 % -80 % recanalization with modern stentrievers) [8]. modified Rankin scale shift at 90 days, the adjusted com-
The SYNTHESIS expansion trial enrolled 362 pa- mon odds ratio was 1.67 in favor of the intervention [2].
tients with AIS to IV tPA within 4.5 h versus IA ther- The REVASCAT trial was halted early citing loss of
apy within 6 h of symptom onset. No pre-procedural equipoise after the publication of the MR CLEAN re-
imaging was required (10 % of patients did not have sults. REVASCAT randomized 206 patients with a prox-
a large vessel occlusion), nor was a lower boundary of imal anterior circulation occlusion without a large
NIHSS at presentation defined (nearly half of enrolled infarct who could be treated within 8 h from symptom
patients had NIHSS scores of 10 or less). Once ran- onset to medical therapy alone (IV tPA) or medical ther-
domized, 165 of 181 patients in the interventional apy and endovascular therapy with the Solitaire stent re-
arm received an endovascular procedure, and only 56 triever. Ischemic core was estimated by ASPECTS,
of these received mechanical thrombectomy. Add- admitting patients only with ASPECTS of 6 to 10;
itionally, the intervention arm received treatment one NIHSS was at least 6 for admission into the trial. This
hour later on average compared to the IV arm. Suc- trial showed benefit of endovascular stroke therapy, with
cess of revascularization was not reported. Despite a common odds ratio of 1.7 in the Rankin shift analysis
lack of confirmation of a large vessel occlusion, with- in favor of endovascular therapy, and 15.5 % absolute
holding of IV tPA, and the delivery of IA tPA to pa- difference in the proportion of patients who were func-
tients without a vessel occlusion, there was no tionally independent at 90 days (43.7 % vs. 28.2 %) [4].
increase in death or intracranial hemorrhage com- The ESCAPE trial was halted early after an interim ana-
pared to IV tPA. Not surprisingly given these short- lysis was prompted by the MR CLEAN results. ESCAPE
comings, the trial failed to show a benefit in 3 month
mRS in the interventional arm [9]. Table 2 TICI Scoring for assessment of procedural success in
The Mechanical Retrieval and Recanalization of acute stroke therapy
Stroke Clots Using Embolectomy (MR RESCUE) Grade TICI Score
Trial was a multi-center randomized trial comparing 0 No Perfusion.
standard medical care to interventional stroke ther-
1 Antegrade reperfusion past the initial occlusion but limited
apy in patients presenting within 8-h with a large distal branch filling with little or slow distal reperfusion.
vessel anterior circulation stroke. All patients received
2a Antegrade reperfusion of less than half of the occluded target
a perfusion MR or CT prior to randomization. Inter- artery previously ischemic territory (e.g. 1 major MCA division
ventional stroke therapy was not superior to standard and its territory).
medical care, but this trial did show that patients 2b Antegrade reperfusion of more than half of the previously
with revascularization had improved 3-month mRS occluded target artery ischemic territory.
(3.2 versus 4.1) and lower median absolute infarct 3 Complete antegrade reperfusion of the previously occluded
growth (9.0 mL vs. 73 mL) [10]. Importantly, MR RESCUE target artery without visualized distal occlusion in all distal
branches.
included first generation thrombectomy devices only, and
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 3 of 12

Fig. 1 (See legend on next page.)

Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 4 of 12

(See figure on previous page.)

Fig. 1 Large ischemic core in a 37-year-old female who awoke with right gaze preference and left sided-weakness. Axial non-contrast computed
tomography (CT) images at the level of the basal ganglia (a) and through the centrum semiovale (b) show hypodensity and loss of grey-white
differentiation of the right insular cortex, putamen, and right frontal grey matter. This is similarly shown by axial diffusion weighted images (c,d).
Cerebral blood volume (CBV) map from the perfusion CT show decreased CBV corresponding to those territories consistent with a large core of
completed infarct (e, f). The Tmax maps demonstrate a matched perfusion deficit (g, h)

recruited 316 patients with a proximal anterior circulation with large core infarcts on the basis of advanced im-
occlusion and randomized to standard of care with IV tPA aging, and higher rates of reperfusion in the endovascu-
vs. standard of care plus endovascular treatment with lar arms. Advanced imaging clearly plays a role in
thrombectomy devices up to 12 h from symptom onset. patient selection for endovascular stroke therapy; the
Patients with large infarct (Alberta Stroke Program Early goal of this paper is to review predictive signs and mea-
CT Score, ASPECTS < 6) or poor collaterals (<50 % filling sures of advanced imaging in acute stroke.
of pial collaterals on CTA) were excluded. This study
showed both an improvement in mRS at 90 days in the Outcome measures in endovascular stroke therapy
interventional arm of 53.0 % vs. 29.3 % as well as a de- Outcome measures in endovascular acute stroke therapy
creased mortality in the interventional arm of 10.4 % vs. may be graded with clinical metrics (e.g. mRS at 90 days)
19.0 % [5]. [13, 14], and with imaging metrics (e.g. TICI reperfusion
The EXTEND-IA trial was also stopped early once the score) [15]. These are well reviewed elsewhere and are
results of MR CLEAN became available, after recruitment summarized in Table 1 and Table 2.
of 70 patients who were receiving IV tPA within 4.5 h from There are numerous fixed clinical variables that impact
symptom onset to interventional treatment with the Soli- the outcome of a stroke patient after reperfusion ther-
taire stent-retriever device or to continuation of IV tPA apy, including presentation NIHSS, baseline functional
alone. Eligible patients were selected with perfusion-CT status, time from stroke onset to reperfusion, patient
and CT-angiogram to have a proximal anterior circulation age, patient comorbidities, etc. In this paper, we focus on
arterial occlusion and an ischemic core of less than 70 mL. imaging findings that can predict procedural success and
Compared with IV tPA alone, endovascular therapy re- clinical outcome.
sulted in a significantly higher probability of reperfusion
(89 % vs. 34 %), and this translated to a significant clinical Results: Imaging predictors of good outcomes in
benefit with more patients in the interventional arm (71 % endovascular stroke therapy
vs. 40 %) achieving functional independence (mRS 0-2) at Side of occlusion
90 days [3]. The laterality of the stroke has a great effect on patient
The SWIFT PRIME study enrolled patients with a outcome, with dominant hemisphere strokes having a
NIHSS > 8 resulting from a proximal anterior circula- greater impact per volume of infarct than a non-
tion arterial occlusion and utilized perfusion-CT dominant hemisphere stroke. In a study relating DWI le-
with automated software to compute the volume of sion volume to poor outcome (mRS >2), the 95 % speci-
core infarct selecting patients with a core <50 cc ficity lesion volume was 51.8 mL for the left hemisphere
(later modified to read baseline evidence of a moder- compared to 98.5 mL for right hemisphere involvement,
ate/large core as defined by ASPECTS < 6). Patients indicating that non-dominant hemisphere strokes are
with a Tmax lesion of >100 cc were excluded (see better tolerated [16]. While some of this difference re-
malignant perfusion profile, below). The treatment lates to an inherent bias of the NIHSS scoring towards
window in SWIFT PRIME was 6 h. Again, this trial dominant hemisphere stroke, it is clear that a dominant
showed a benefit of endovascular therapy showing a hemisphere infarct portends a worse prognosis.
number needed to treat of only 2.6 for an improved
disability outcome, and of only 4 patients for one Ischemic core estimation
additional patient to be functionally independent at The size of the completed infarct when a patient presents
90 days [12]. with a stroke represents irrecoverable damage and there-
Beyond the proven clear benefit of endovascular stroke fore more than success of recanalization sets the stage for
therapy, there are lessons to be learned. Three studies how much recovery can be expected [17]. Ischemic core
that showed the highest frequency of functional inde- size is an independent predictor of outcome after stroke,
pendence were the SWIFT PRIME (60 %), the ESCAPE whether measured by CT or DWI MR (Fig. 1) [18–21]. In
trial (53 %) and the EXTEND IA trial (71 %). This likely a retrospective study, good outcome (mRS 0-2) occurred
reflects commonalities among these trials including fast with average lesion volumes of 16.3 mL whereas the aver-
time to endovascular therapies, exclusion of patients age lesion size in poor outcome (mRS >2) was 63.4 mL
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 5 of 12

Fig. 2 Dense middle cerebral artery (MCA) sign with an ischemic penumbra in a 68-year-old male with acute stroke. Non-contrast computed
tomography (CT) demonstrates a dense left MCA with long length of thrombus (a). This manifests “blooming” on gradient recalled echo (GRE, b)
magnetic resonance imaging. CT angiography (CTA) shows a left carotid terminus occlusion extending into the left middle cerebral artery (c), with
a better depiction of collaterals than can be seen on the time-of-flight magnetic resonance angiogram (MRA, d). Diffusion weighted MR image
(DWI, e) and perfusion weighted MRI Tmax map with colorized overlay representing the infarcted core (pink, e) and the territory at risk (green, f),
here showing a favorable perfusion pattern with a small ischemic core and large penumbra

again demonstrating the link between lesion size at presen- stroke is highly correlative with final stroke volume, with
tation and outcome [16]. When measured by MRI at 48 h, normalization of brain tissue previously showing abnormal
the infarct volume is an independent predictor of outcome DWI signal (“DWI reversal”) representing an unlikely
[18]. The estimation of ischemic core by DWI during acute event. When DWI reversal does occur it is not of sufficient
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 6 of 12

size to meaningfully alter the degree of diffusion-perfusion similar success (61 % and 59 %, respectively) with similar
mismatch [22]. proportions of good clinical outcome after revascularization
Because MRI is difficult to obtain at many centers alter- of 65 % for ICA recanalization and 63 % for MCA recanali-
nate methods have been devised to estimate ischemic core zation [33].
with CT. The Alberta Stroke Program Early CT Score (AS- Even when applied to the M1 segment, patients
PECTS) divides the brain into 10 territories with points re- harboring proximal M1 segment MCA lesions are less
moved for loss of grey matter-white matter differentiation likely to have a good functional outcome compared to
in each territory based on a non-contrast CT evaluation distal M1 segment MCA lesions (8 % vs. 39 %), and are
[23]. This score has been shown repeatedly to correlate more likely to sustain a basal ganglia infarct comprising
with outcome; for instance when applied to the National the internal capsule (83 % vs. 11 %) [34]. A similar study
Institute of Neurological Disorders and Stroke (NINDS) examined patient outcome based on location of hyper-
cohort, ASPECTS 8-10 group had a greater benefit from dense MCA sign, and showed improved clinical outcome
IV thrombolysis and a trend toward reduced mortality in distal as compared with proximal sites of occlusion
[24]. In the original study ASPECTS score of 7 or below (85 % vs. 15 % mRS 0-2) [35].
demarcated good from poor outcomes [23]. The rate of
change of ASPECTS score in patients transferred to a com- Clot characteristics
prehensive stroke center having already undergone a CT Thrombus is most commonly the cause of ischemic
scan at an outside hospital is likely a reflection of collateral stroke, but not every thrombus is the same. Thrombus
perfusion and is also predictive of outcome [25]. subtype has been stratified into platelet-rich and red
Perfusion CT (PCT) imaging is used at many stroke cen- blood cell-rich varieties, and this distinction has been
ters to triage patients to appropriate therapy because it is shown to have an effect on success of tPA and on inter-
fast to obtain and nearly universally available. The primary ventional stroke therapy [36]. Surrogate markers of clot
goal of perfusion imaging is to differentiate ischemic core composition include density on non-contrast CT, and
from the penumbra [26]. Within an ischemic core both the degree of blooming artifact on GRE MR images
cerebral blood flow (CBF) and cerebral blood volume (Fig. 2). Dense clots on CT and blooming clots on GRE
(CBV) are lowered; CBV is the most accurate predictor of MRI both imply a red blood cell predominant compos-
the core infarct [27]. A trial investigating whether PCT can ition. Red cell predominant clots infer a favorable re-
predict response to recanalization, Computed Tomography sponse to both IV and IA stroke therapies compared
Perfusion to Predict Response to Recanalization in Ischemic with clots of lower density or without GRE blooming
Stroke Project (CRISP), is ongoing [28]. artifact [37].
The length of thrombus, also described as clot burden,
Clot location has been shown to predict likelihood of recanalization, as
The location of the occluded vessel has an effect both on well as final stroke outcome. In one study, no thrombus
success of revascularization but also on clinical outcomes. exceeding 8-mm in length resulted in recanalization after
Large vessel occlusion, defined in one study as vertebral, treatment with IV tPA [38]. Another study in which 54 %
basilar, internal carotid, proximal (M1 segment) middle of patients received IV tPA and the other 46 % received IV
cerebral and proximal (A1 segment) anterior cerebral ar- tPA plus IA therapy, recanalization was achieved 85 % of
tery occlusion, correlates to worse outcome. Specifically, the time for thrombi <10 mm, 37.5 % for thrombi 10-
the odds ratio for mortality is 4.5 and the odds ratio of 20 mm, and in no cases for thrombi >20 mm, demonstrat-
good outcome (mRS ≤2) is 0.33 in patients with a large ing that a longer thrombus is more resistant to both IV
vessel occlusion compared to those without [29]. and IA therapies [39]. When a “clot burden” score is
In patients treated with IV tPA, the rates of complete re-
canalization for ICA terminus, proximal MCA, and distal Table 3 ASITN/SIR Collateral flow grading system
MCA are 5 %, 10 % and 22 %, respectively [30]. In the Grade 0 No collaterals visible to the ischemic site
SWIFT trial, the ICA, M1 MCA, and M2 MCA made up
Grade 1 Slow collaterals to the periphery of the ischemic site
21 %, 66 %, and 10 %, respectively, of patients randomized with persistence of some of the defect
to the Solitaire device with overall recanalization of 69 %
Grade 2 Rapid collaterals to the periphery of ischemic site
as assessed by the core laboratory [31]. In TREVO2, rates with persistence of some of the defect and to only
of ICA, M1 and M2 enrollment were 16 %, 60 %, and a portion of the ischemic territory
16 %, respectively, with overall recanalization (TICI ≥2) of Grade 3 Collaterals with slow but complete angiographic blood
86 % [32]. More proximal occlusions are therefore much flow of the ischemic bed by the late venous phase
less likely to respond to IV compared to IA therapy. In the Grade 4 Complete and rapid collateral blood flow to the vascular
DEFUSE2 trial, using largely first-generation thrombectomy bed in the entire ischemic territory by retrograde
perfusion
devices, ICA and MCA occlusions were revascularized with
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 7 of 12

Fig. 3 (See legend on next page.)

Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 8 of 12

(See figure on previous page.)

Fig. 3 Favorable collaterals in a 67-year-old with acute right MCA occlusion. Axial maximum intensity projection (MIP) of the CTA show a right
M1 segment MCA occlusion (a) with excellent collateral filling of the affected territory (a, b). Correlative CTP shows no CBV evidence of a
completed core infarct (c, d). A large ischemic penumbra is evident on the Tmax maps (e, f). Colorized threshold maps demonstrate a small
region of core infarct (pink, g) with a relatively large territory at risk (green, h)

allocated for thrombotic occlusion of vascular territories, Penumbra imaging

increasing clot burden is associated with both worse func- Estimate of the ischemic penumbra in acute stroke in rela-
tional outcome as well as with larger final infarct as tion to the core infarct is a critical piece of information
assessed by ASPECTS score [40]. Looking forward, im- when triaging candidates for interventional stroke therapy.
aging may serve as a tool to better define clot constituents While ischemic penumbra is present in 90 % to 100 % of
and help guide treatment decisions based on probability of patients with anterior circulation stroke in a three hour
success for a given clot composition. window, 75 % to 80 % continue to have some degree of
penumbral tissue at 6 h [26]. Selecting patients with pre-
served tissue at risk prevents futile reperfusion of infarcted
Collateral scoring tissue and improves outcomes in stroke therapy [2–5]. In-
In ischemic stroke, neuronal loss occurs at an average deed, recent trials that selected patients for endovascular
rate of 1.9 million per minute [41]. While this number is stroke therapy with perfusion imaging show the largest
grossly simplified, it speaks to the exquisite sensitivity of benefit [2, 3]. This estimate may be made clinically using
a neuron to oxygen debt. It therefore stands to reason the NIHSS as a surrogate marker of ischemia, but using
that collateral flow is a critical factor in determining PCT imaging adds specificity and reproducibility to this es-
both the rate of stroke completion and the extent of in- timate (Fig. 4). Penumbral information as assessed by PCT
volvement of the affected hemisphere. A recent review provides information that cannot be inferred clinically, and
cited 63 different methods of assessing collateral flow, is an independent predictor of stroke outcome. An import-
however the most commonly used method, developed ant point with respect to perfusion imaging is a finding
by the American Society of Interventional and Therapeutic termed the malignant profile, which denotes a large lesion
Neuroradiology (ASITN) and the Society of Interventional with markedly delayed perfusion as defined by a DWI
Radiology (SIR) is summarized in Table 3 [42]. core > 100 mL or a perfusion-weighted image lesion of
High quality collaterals have been shown to be inde- 100 mL or more with Tmax delay of 8 s or more. The ma-
pendent predictors of both favorable outcome and re- lignant profile is associated with poor outcome and a
canalization (Fig. 3) [43–46]. When applied to stroke, a higher rate of symptomatic intracranial hemorrhage after
malignant profile representing a complete lack of collat- interventional stroke therapy (Fig. 5) [52].
eral vessels in the affected territory, is a discriminator of
lesion volume >100 mL (itself a strong predictor of out- White matter injury
come), and of being functionally dependent (mRS ≥ 3) at Diffusion tensor imaging (DTI) allows visualization of
3 months [47]. white matter tracts, the injury of which has prognostic
Good collaterals are a strong predictor of recanalization; value in acute stroke. For instance, the integrity of the
conversely patients with poor collaterals are less likely to corticospinal tract as assessed by MRI can predict the
achieve recanalization and more likely to have hemorrhagic probability of motor recovery after corona radiata stroke
transformation [48, 49]. In the ENDOSTROKE study, bet- [53–55]. In the acute stage, diffusion tractography pre-
ter collateral vessels (ASITN/SIR grades of 0 or 1, 2, and 3 dicted motor function at 90 days better than clinical
or 4) were associated with higher reperfusion rates (21 %, scores [55].
48 %, and 77 %), a higher proportion of infarcts smaller
than one-third of the MCA territory (32 %, 48 %, and Blood-brain barrier (BBB) permeability
69 %), and a higher proportion of good clinical outcome Symptomatic intracranial hemorrhage is a complica-
(11 %, 35 %, and 49 %) [50]. tion of endovascular stroke therapy with an incidence
In the ESCAPE trial of endovascular stroke therapy, in ranging from 0-7.7 % in recent trials [2–5]. This can
addition to proof of small infarct core and proximal ves- have important consequences for final outcome after
sel occlusion, patients were selected on the basis of a endovascular stroke therapy and therefore it is im-
moderate to good collateral score, which has also been portant to have imaging metrics to prospectively ex-
shown to be an independent predictor of outcome after clude patients who are at a high risk of hemorrhage
stroke [5, 51]. Good patient selection in this trial clearly from endovascular therapies. The hyperintense acute
contributed to the favorable treatment results, highlight- reperfusion marker (HARM) is an early marker of
ing the value of collateral scoring. BBB breakdown, observed as hyperintense signal seen
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 9 of 12

A B

C D

E F

G H
Fig. 4 (See legend on next page.)
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 10 of 12

(See figure on previous page.)

Fig. 4 Large ischemic penumbra with small core infarct in a 73 year-old with acute stroke. MRA shows acute M1 segment MCA vessel cutoff
(arrow, a). Blooming artifact localizes to the occlusive thrombus on the GRE image (arrow, b). Apparent diffusion coefficient (a, d, c) map (c, d)
demonstrating a small region of core infarct (arrowhead). CBV maps from the PCT show no region of decrease to suggest a large core infarct
(e, f). Ischemic penumbra comprises the majority of the left MCA territory on the Tmax maps (g, h)

Fig. 5 Malignant perfusion profile in an 82-year-old with a right MCA syndrome. MRA showing a right M1 segment MCA occlusion (a). GRE image
demonstrates blooming from thrombus at the site of occlusion (b, arrow). DWI image demonstrates a moderate-sized ischemic core (c), which is
colorized on the perfusion map (pink, d). The ischemic penumbra is larger than the ischemic core (green, e) but in this instance is notable for a
large volume of Tmax > 10s consistent with a malignant perfusion profile (f)
Telischak and Wintermark Neurovascular Imaging (2015) 1:4 Page 11 of 12

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