Final Infarct Volume as a Surrogate End Point in Anterior Circulation ICAS-LVO Stroke: Post Hoc Secondary Analysis of RESCUE-ICAS

BACKGROUND: Final infarct volume (FIV) on 24-hour magnetic resonance imaging is a well-established imaging biomarker linked to functional recovery after ischemic stroke, yet its prognostic value in intracranial atherosclerosis–related large vessel occlusion remains poorly explored. The impact of adjunct intracranial stenting on both infarct size and progression also remains unclear in this population. This study aimed to examine the association between FIV and clinical outcome, evaluate the effect of adjunct stenting on FIV and infarct progression, and assess the relationship between infarct progression and functional independence. METHODS: We conducted a post hoc secondary analysis of the RESCUE-ICAS registry (Registry of Emergent Large Vessel Occlusion due to Intracranial Stenosis); only patients with anterior circulation large vessel occlusion with magnetic resonance imaging after thrombectomy were included. FIV was measured on diffusion-weighted magnetic resonance imaging performed 24 to 36 hours postthrombectomy. Infarct progression was defined as the difference between baseline computed tomography perfusion infarct volume (cerebral blood flow <30%) on presentation and 24- to 36-hour FIV. The primary outcome was 90-day functional independence (modified Rankin Scale score 0–2). Additional analyses evaluated the association between adjunct intracranial stenting and FIV, and the association between infarct progression and 90-day functional outcome. Associations were analyzed using multivariable logistic regression and inverse probability of treatment weighting. RESULTS: Of the 417 patients included in RESCUE-ICAS, 203 had anterior circulation intracranial atherosclerosis–related large vessel occlusion and underwent magnetic resonance imaging 24 to 36 hours postthrombectomy. Among these, 80 patients (39%) received adjunct stenting. FIV was independently associated with 90-day functional independence (adjusted odds ratio per 10 mL increase, 0.8 [95% CI, 0.68–0.94]; P =0.007). Adjunct stenting was associated with a significant relative reduction in FIV, with inverse probability of treatment weighting–adjusted analyses demonstrating a 37.8% lower FIV compared with no stenting ( β =−0.47 [95% CI, −0.93 to −0.02]; P =0.043). Among 108 patients with baseline computed tomography perfusion data, infarct progression was strongly associated with outcome, with each additional 10 mL associated with ≈25% lower odds of achieving modified Rankin Scale score 0 to 2 at 90 days (adjusted odds ratio, 0.74 [95% CI, 0.60–0.90]; P =0.004), although infarct progression did not differ significantly between stented and nonstented groups (Δ −9.53 mL [95% CI −37.9 to 18.8]; P =0.506). In inverse probability of treatment weighting–weighted models adjusted for successful recanalization, stenting was not independently associated with reduced FIV ( β =−0.41; P =0.066), but remained independently associated with higher odds of 90-day functional independence (odds ratio, 2.29 [95% CI, 1.24–4.27]; P =0.008). CONCLUSIONS: Among intracranial atherosclerosis–related large vessel occlusion patients, 24- to 36-hour FIV is a strong predictor of functional outcome. Adjunct stenting is associated with smaller FIV. Lower infarct progression was also associated with favorable outcome. These findings highlight FIV as a reliable imaging biomarker and potential surrogate end point in future trials.

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Journal
Stroke Vascular and Interventional Neurology
Published
2026-06-17
DOI
https://doi.org/10.1161/svin.125.002105
Primary Topic
Acute Ischemic Stroke Management
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article
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article

Final Infarct Volume as a Surrogate End Point in Anterior Circulation ICAS-LVO Stroke: Post Hoc Secondary Analysis of RESCUE-ICAS

Stacey Q Wolfe, Osama O. Zaidat, Eytan Raz, Syed Zaidi et al.
Stroke Vascular and Interventional Neurology
Acute Ischemic Stroke Management
article

Final Infarct Volume as a Surrogate End Point in Anterior Circulation ICAS-LVO Stroke: Post Hoc Secondary Analysis of RESCUE-ICAS

Stacey Q Wolfe, Osama O. Zaidat, Eytan Raz, Syed Zaidi, Muhammad Niazi, J Lena, Jonathan Andrew Grossberg, Shadi R. Yaghi, Mohamad K. Abdalkader, Ilko Maier, A Mierzwa, Stavropoula I. Tjoumakaris, David Altschul, Ramesh Grandhi, Mohamad Ezzeldin, Kimberly Kicielinski, Mohammed Almekhlafi, Eyad Almallouhi, Edgar Andres Samaniego, Francesco Capasso, Sami Al Kasab, Adam de Havenon, Nitin Goyal, Thanh N. Nguyen, Robert William Regenhardt, Pascal M. Jabbour, Marios‐Nikos Psychogios, Violiza Inoa, Michael Nahhas, Ali Mostafa Alawieh, Colin P. Derdeyn, Mustafa Ismail, Kaustubh Limaye, Ameer E Hassan, Mouhammad A. Jumaa, Hosam Al-Jehani, Isabel Fragata, Krisztina Moldovan, Brian T. Jankowitz, A. M. Abdel-Wahab, Ahmad Abu Qdais, Robert M Starke, Justin Mascitelli, Alejandro M. Spiotta, Ashley Choi, Zachary Hubbard, Matthew T. Bender, Jan-Karl Burkhardt
article en

Abstract

BACKGROUND: Final infarct volume (FIV) on 24-hour magnetic resonance imaging is a well-established imaging biomarker linked to functional recovery after ischemic stroke, yet its prognostic value in intracranial atherosclerosis–related large vessel occlusion remains poorly explored. The impact of adjunct intracranial stenting on both infarct size and progression also remains unclear in this population. This study aimed to examine the association between FIV and clinical outcome, evaluate the effect of adjunct stenting on FIV and infarct progression, and assess the relationship between infarct progression and functional independence. METHODS: We conducted a post hoc secondary analysis of the RESCUE-ICAS registry (Registry of Emergent Large Vessel Occlusion due to Intracranial Stenosis); only patients with anterior circulation large vessel occlusion with magnetic resonance imaging after thrombectomy were included. FIV was measured on diffusion-weighted magnetic resonance imaging performed 24 to 36 hours postthrombectomy. Infarct progression was defined as the difference between baseline computed tomography perfusion infarct volume (cerebral blood flow <30%) on presentation and 24- to 36-hour FIV. The primary outcome was 90-day functional independence (modified Rankin Scale score 0–2). Additional analyses evaluated the association between adjunct intracranial stenting and FIV, and the association between infarct progression and 90-day functional outcome. Associations were analyzed using multivariable logistic regression and inverse probability of treatment weighting. RESULTS: Of the 417 patients included in RESCUE-ICAS, 203 had anterior circulation intracranial atherosclerosis–related large vessel occlusion and underwent magnetic resonance imaging 24 to 36 hours postthrombectomy. Among these, 80 patients (39%) received adjunct stenting. FIV was independently associated with 90-day functional independence (adjusted odds ratio per 10 mL increase, 0.8 [95% CI, 0.68–0.94]; P =0.007). Adjunct stenting was associated with a significant relative reduction in FIV, with inverse probability of treatment weighting–adjusted analyses demonstrating a 37.8% lower FIV compared with no stenting ( β =−0.47 [95% CI, −0.93 to −0.02]; P =0.043). Among 108 patients with baseline computed tomography perfusion data, infarct progression was strongly associated with outcome, with each additional 10 mL associated with ≈25% lower odds of achieving modified Rankin Scale score 0 to 2 at 90 days (adjusted odds ratio, 0.74 [95% CI, 0.60–0.90]; P =0.004), although infarct progression did not differ significantly between stented and nonstented groups (Δ −9.53 mL [95% CI −37.9 to 18.8]; P =0.506). In inverse probability of treatment weighting–weighted models adjusted for successful recanalization, stenting was not independently associated with reduced FIV ( β =−0.41; P =0.066), but remained independently associated with higher odds of 90-day functional independence (odds ratio, 2.29 [95% CI, 1.24–4.27]; P =0.008). CONCLUSIONS: Among intracranial atherosclerosis–related large vessel occlusion patients, 24- to 36-hour FIV is a strong predictor of functional outcome. Adjunct stenting is associated with smaller FIV. Lower infarct progression was also associated with favorable outcome. These findings highlight FIV as a reliable imaging biomarker and potential surrogate end point in future trials.

Stroke Vascular and Interventional Neurology
Boston University (US), Boston Medical Center (US), Mercy St. Vincent Medical Center (US), Albert Einstein College of Medicine (US), University of Miami (US), Thomas Jefferson University (US), Emory University (US), Medical University of South Carolina (US), The University of Texas at San Antonio Health Science Center (US), University of Calgary (CA), University of Utah (US), Brown University (US), King Fahd Hospital of the University (SA), University of Iowa Hospitals and Clinics (US), University Hospital of Basel (CH), University of Rochester Medical Center (US), Yale University (US), NYU Langone Health (US), Massachusetts General Hospital (US), Hospital de São José (PT), WellSpan Health (US), Semmes Murphey Foundation (US), Sarasota Memorial Hospital (US), Valley Baptist Medical Center (US), Lone Star College Kingwood (US), University of Houston (US), University of Florence (IT), Wake Forest University (US), University of Virginia (US), Indiana University – Purdue University Indianapolis (US), University of Göttingen (DE), University of Pennsylvania (US), University of Toledo (US), The University of Texas Health Science Center at Houston (US)
Good health and well-being
Openalex Percentile: Top 7%
Acute Ischemic Stroke Management
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