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Futile Recanalization With Poor Clinical Outcome Is Associated With Increased Edema Volume After Ischemic Stroke

Nawabi, Jawed, MD*; Flottmann, Fabian, MD*; Hanning, Uta, MD, MHBA*; Bechstein, Matthias, MD*; Schön, Gerhard, MSc; Kemmling, Andre, MD, MHBA; Fiehler, Jens, MD*; Broocks, Gabriel, MD*

doi: 10.1097/RLI.0000000000000539
Original Articles

Purpose Futile recanalization with poor clinical outcome after endovascular treatment of acute ischemic stroke is poorly understood. Recently, vessel recanalization has been associated with reduced ischemic brain edema in patients with good clinical outcome. As edema volume (EV) may be quantified in computed tomography (CT), we hypothesized that higher EV after revascularization predicts futile recanalization with poor outcome.

Methods In this observational study, 67 ischemic stroke patients with M1 middle cerebral artery occlusion fulfilled all inclusion criteria and were analyzed. All patients received successful endovascular recanalization (thrombolysis in cerebral infarction scale 2b/3) and subsequent follow-up CT 24 hours later. Edema volume within the infarct lesion was calculated in follow-up CT applying lesion water uptake quantification and was used to predict clinical outcome (Modified Rankin Scale [mRS] after 90 days) compared with infarct volume.

Results The median EV after thrombectomy was 1.6 mL (interquartile range, 0.2–4.2 mL) in patients with mRS 0 to 4 and 8.6 mL (interquartile range, 2.0–49.8 mL) in patients with mRS 5 to 6 (P = 0.0008). In regression analysis, an EV increase of 1 mL was associated with an 8.0% increased likelihood of poor outcome (95% confidence interval, 2.8%–15.4%; P = 0.008). Based on univariate receiver operating characteristic curve analysis, absolute EV over 4.2 mL predicted poor outcome (mRS 5–6) with good discriminative power (area under curve, 0.74; 95% confidence interval, 0.62–0.84; specificity, 77%; sensitivity, 68%). In comparison, the area under curve for infarct volume was 0.68.

Conclusions Elevated EV after endovascular thrombectomy was associated with poor clinical outcome and may indicate futile recanalization.

From the *Department of Diagnostic and Interventional Neuroradiology, and

Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg; and

Department of Radiology, University Hospital Muenster, Muenster, Germany.

Received for publication October 25, 2018; and accepted for publication, after revision, November 5, 2018.

Conflicts of interest and sources of funding: J.F. is a consultant for Acandis, Boehringer Ingelheim, Codman, Microvention, Sequent, and Stryker; is a speaker for Bayer Healthcare, Bracco, Covidien/ev3, Penumbra, Philips, and Siemens; and received grants from Bundesministeriums für Wirtschaft und Energie, Bundesministerium für Bildung und Forschung, Deutsche Forschungsgemeinschaft, European Union, Covidien, Stryker (THRILL study), Microvention (ERASER study), and Philips. A.K. is part of the research collaboration agreement, Siemens Healthcare. All the other authors have nothing to disclose.

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Correspondence to: Gabriel Broocks, MD, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. E-mail:

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