Clinical benefit of thrombectomy in stroke patients with low ASPECTS is mediated by oedema reduction

Broocks, Gabriel; Hanning, Uta; Flottmann, Fabian; Schönfeld, Michael; Faizy, Tobias D.; Sporns, Peter; Baumgart, Michael; Leischner, Hannes; Schön, Gerhard; Minnerup, Jens; Thomalla, Götz; Fiehler, Jens; Kemmling, André

doi:10.1093/brain/awz057

Cited by 145 publications

(131 citation statements)

References 31 publications

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“…Successful recanalization was associated with a seven-fold higher likelihood of an independent outcome. This confirms the findings from previous studies of ET in low ASPECTS patients that consistently identified successful recanalization to be one of the strongest predictors of good outcome in this important subgroup of patients 13 17 18…”

Section: Discussionsupporting

confidence: 89%

Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis

Deb‐Chatterji

Pinnschmidt

Flottmann

et al. 2020

J NeuroIntervent Surg

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ObjectiveTo analyze outcome and its predictors after endovascular treatment (ET) in stroke patients suffering from large vessel occlusion with large pre-treatment infarct cores defined by an Alberta Stroke Program Early CT Score (ASPECTS) <6.MethodsWe analyzed data from an industry-independent, multicenter, prospective registry (German Stroke Registry – Endovascular Treatment) which enrolled consecutive patients treated by ET (June 2015–April 2018) with different devices. Multivariate logistic regression analyses identified predictors of independent outcome (IO) defined as a modified Rankin Scale (mRS) 0–2, and mortality at 90 days in patients with ASPECTS <6.ResultsOf 1700 patients included in the analysis, 152 (8.9%) had a baseline ASPECTS <6. Of these, 33 patients (21.6%) achieved IO, and 68 (44.7%) were dead at 90 days. A lower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) were predictors of IO. Successful recanalization had the strongest association with IO (OR 7.0, 95% CI 1.8 to 26.8). Pre-treatment parameters predicting IO were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57 and 0.94). A higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.ConclusionsA substantial proportion of stroke patients with an ASPECTS <6 can achieve independence after thrombectomy, in particular, if they are younger, have only moderate baseline stroke symptoms, and no relevant pre-stroke disability. These results may encourage considering thrombectomy in low ASPECTS patients in clinical practice until randomized trials are available.

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Section: Discussionsupporting

confidence: 89%

Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis

Deb‐Chatterji

Pinnschmidt

Flottmann

et al. 2020

J NeuroIntervent Surg

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“…Finally, using a CT-based biomarker of brain ischaemic edema, a recent multicenter observational study demonstrated that reperfusion may reduce follow-up infarct volume and decrease the occurrence of MMI. However, in the latter study, EVT was only performed in 28% of the non-reperfused patient group [15]. Most of these previous studies included patients with low CT score or DWI-ASPECTS, but it is well known that there is an imperfect correlation between infarct volume and DWI-ASPECTS, especially when the deep brain is damaged [11].…”

Section: Discussionmentioning

confidence: 99%

Early successful reperfusion after endovascular therapy reduces malignant middle cerebral artery infarction occurrence in young patients with large diffusion‐weighted imaging lesions

Sabben

Desilles

Charbonneau

et al. 2020

Euro J of Neurology

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Background and purpose Malignant middle cerebral artery infarction (MMI) is a severe complication of acute ischaemic stroke (AIS). The aim of our study was to assess whether successful reperfusion after endovascular therapy (EVT) in AIS with clinical and imaging predictors of MMI decreased its occurrence. Methods Data were collected between January 2014 and July 2018 in a monocentric prospective AIS registry of patients treated with EVT. Patients selected were <65 years old with severe anterior circulation AIS with a National Institutes of Health Stroke Scale score >15, baseline Diffusion‐Weighted Imaging‐Alberta Stroke Program Early Computed Tomography Score ≤ 6 and baseline diffusion‐weighted imaging lesion volume >82 mL within 6 h of symptom onset. Successful reperfusion was defined as a Thrombolysis in Cerebral Ischemia score ≥ 2b. Occurrence of MMI was the primary endpoint. Results A total of 66 EVT‐treated patients were included in our study. MMI occurred in 27 patients (41%). In unadjusted analysis, successful reperfusion was associated with fewer MMIs (31.8% vs. 65.0%; P = 0.015) and with more favorable outcome at 3 months (50% vs. 20%; P = 0.023). In multivariate analysis, successful reperfusion was associated with an adjusted odds ratio (95% confidence intervals) of 0.35 (0.10–1.12) for MMI and 2.77 (0.84–10.43) for 3‐month favorable outcome occurrence. Conclusions Early successful reperfusion performed in patients with AIS with clinical and imaging predictors of MMI was associated with decreased MMI occurrence. Reperfusion status might be considered in evaluating the need for craniectomy in patients with early predictors of MMI.

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“…This implies that edema reduction may mediate the benefit seen in this subset of patients. 39 ASPECTS relies on the ability of the reader to determine early ischemic changes, such as focal swelling and parenchymal hypoattenuation in the territory of the middle cerebral artery. 40 It has been shown to have good interobserver reliability in its use for intra-arterial stroke treatment selection.…”

Section: Summary Of Evidencementioning

confidence: 99%

Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis

Diestro

Dmytriw

Broocks

et al. 2020

Can. J. Neurol. Sci.

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Background: The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6. Objective: We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less). Methods: Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only. Results: Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group. Conclusions: This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.

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Clinical benefit of thrombectomy in stroke patients with low ASPECTS is mediated by oedema reduction

Cited by 145 publications

References 31 publications

Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis

Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis

Early successful reperfusion after endovascular therapy reduces malignant middle cerebral artery infarction occurrence in young patients with large diffusion‐weighted imaging lesions

Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis

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