Elena Zapata-Arriaza, MD

Ospel JM, Hill MD, Kappelhof M, Demchuk AM, Menon BK, Mayank A, Dowlatshahi D, Frei D, Rempel JL, Baxter B, Goyal M. Which Acute Ischemic Stroke Patients Are Fast Progressors? Results From the ESCAPE Trial Control Arm. Stroke. 2021;52:1847-1850.

Time is brain; however, there are patients for whom that time runs faster. Penumbra brain tissue, due to large vessel occlusion, tends to progress to ischemia in the absence of intracranial reperfusion. However, there are a number of conditions that cause a faster progression (rapid progressors) or not, even in those who will receive endovascular treatment. To identify acute ischemic stroke patients with rapid infarct growth, Ospel and colleagues performed a post hoc analysis of the ESCAPE trial (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) in order to investigate baseline clinical and imaging characteristics of fast progressors stroke patients.

The authors included control arm patients if they had follow-up imaging at 2-8 hours without substantial recanalization, and if their baseline Alberta Stroke Program Early CT Score was ≥9. Fast infarct progression was defined as Alberta Stroke Program Early CT Score decay ≥3 points from baseline to 2- to 8-hour follow-up imaging.

Among 43 included patients, fast infarct progression occurred in 15 patients (34.9%). Fast progressors had worse collaterals (poor in 20% versus 0 patients, P=0.021) and more carotid-T or -L occlusions (53.4% versus 10.7%, P=0.021). In 53.3%, occlusion site and circle of Willis configuration prevented collateral flow via the anterior or posterior cerebral artery.

Despite the small sample size, which prevents multivariate analysis, having a group of patients in the control arm, who will evolve towards ischemia, makes the results yield interesting revelations that today could not be obtained given the proven efficacy of thrombectomy. This study supports the importance of having good collaterals or an intracranial occlusion site that facilitates its function to put on our side the most determining factor in ischemic stroke: time. Currently, we do not have therapies that favor the formation of robust collaterals once the occlusion of the large vessel occurs. Beyond the control of blood pressure, the patient’s own endogenous factors are those that will allow the patient to maintain the penumbra for a longer time. That is why time is brain, but for some, that time passes faster than for others.