Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

Katsanos, Aristeidis H.; Catanese, Luciana; Shoamanesh, Ashkan

doi:10.1212/wnl.0000000000207869

Cited by 9 publications

(3 citation statements)

References 8 publications

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“…Our findings support the transfer and treatment consideration of patients with large ischemic core stroke presenting to non–EVT-capable centers as well as exploration of opportunities to further optimize clinical outcomes by reducing potential stroke evolution on neuroimaging during transfer through other therapeutic approaches, such as neuroprotection. On the other hand, a 2023 meta-analysis demonstrated that EVT improves outcomes even in patients with very low ASPECTS (0 to 2) . A randomized clinical trial has included patients with ASPECTS of 0 to 2 and their findings, if confirming beneficial effects of EVT in this population, may further support the notion of transferring patients even with very low ASPECTS or longer transfer times for consideration of thrombectomy procedures.…”

Section: Discussionmentioning

confidence: 99%

Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes

Sarraj,

Hill,

Hussain

et al. 2024

JAMA Neurol

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ImportancePatients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT).ObjectiveTo assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes.Design, Setting, and ParticipantsThis prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024.InterventionsEVT vs MM.Main Outcomes and MeasuresFunctional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication.ResultsA total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80).Conclusions and RelevanceBoth directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport.Trial RegistrationClinicalTrials.gov Identifier: NCT03876457

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Section: Discussionmentioning

confidence: 99%

Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes

Sarraj,

Hill,

Hussain

et al. 2024

JAMA Neurol

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“…12 However, our study enrolled patients within 24 hours of witnessed symptoms and the median time of onset to recanalization was approximately 7 hours, which exceeded the inclusion criteria of less than 6.5 hours since last-known-well time in the LASTE trial. 12 A systematic review and meta-analysis 6 found a statistically significant shift in the distribution of mRS scores toward better outcomes in favor of EVT in the pooled analyses of 82 participants enrolled in 2 individual RCTs. However, EVT was not associated with improved 90-day functional outcomes in patients with ASPECTS of 3 or less in the RESCUE-Japan LIMIT trial.…”

Section: Discussionmentioning

confidence: 99%

“…In a systematic review and meta-analysis of subgroups of patients with baseline ASPECTS of 0 to 2 included in the ANGEL-ASPECT trial and SELECT2 trial, a statistically significant shift in the distribution of modified Rankin Scale (mRS) scores toward better outcomes in favor of EVT was observed in the pooled analyses. In the RESCUE-Japan LIMIT trial, EVT was not associated with improved 90-day functional outcomes in patients with ASPECTS of 3 or less.…”

Section: Introductionmentioning

confidence: 99%

Endovascular Therapy and Outcomes Among Patients With Very Large Ischemic Core Stroke

Xie,

Huang,

Fan

et al. 2024

JAMA Netw Open

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ImportanceThe association of endovascular therapy (EVT) with outcomes is unclear for patients with very low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) within 24 hours of stroke onset.ObjectiveTo explore the association of EVT with functional and safety outcomes among patients with ASPECTS of 0 to 2 scored with noncontrast computed tomography.Design, Setting, and ParticipantsThis cohort study used data from an ongoing, prospective, observational, nationwide registry including all patients treated at 38 stroke centers in China with an occlusion in the internal carotid artery or M1 or M2 segment of the middle cerebral artery within 24 hours of witnessed symptom onset. Patients with ASPECTS of 0 to 2 between November 1, 2021, and February 8, 2023, were included in analysis. Data were analyzed October to November 2023.ExposuresEVT vs standard medical treatment (SMT).Main Outcomes and MeasuresThe primary outcome was favorable functional outcome, defined as modified Rankin Scale score (mRS) of 0 to 3, at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 48 hours and mortality at 90 days.ResultsA total of 245 patients (median [IQR] age, 71 [63-78] years; 118 [48%] women) with ASPECTS of 0 to 2 were included, of whom 111 patients (45.1%) received SMT and 135 patients (54.9%) received EVT. The EVT group had significantly greater odds of favorable functional outcome at 90 days than the SMT group (30 patients [22.2%] vs 11 patients [9.9%]; P = .01; adjusted odds ratio [aOR], 3.07 [95% CI, 1.29-7.31]; P = .01). Patients in the EVT group, compared with the SMT group, had significantly greater odds of any ICH (56 patients [41.5%] vs 16 patients [11.4%]; P &lt; .001; aOR, 4.27 [95% CI, 2.19-8.35]; P &lt; .001) and sICH (24 patients [17.8%] vs 1 patient [0.9%]; P &lt; .001; aOR, 23.07 [95% CI, 2.99-177.79]; P = .003) within 48 hours. There were no differences between groups for 90-day mortality (80 patients [59.3%] vs 59 patients [53.2%]; P = .34; aOR, 1.38 [95% CI, 0.77-2.47]; P = .28). The results remained robust in the propensity score–matched analysis.Conclusions and RelevanceIn this cohort study of patients with very low ASPECTS based on NCCT within 24 hours of stroke onset, those treated with EVT had higher odds of a favorable functional outcome compared with those who received SMT. Randomized clinical trials are needed to assess these findings.

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Endovascular Stroke Thrombectomy for Patients With Large Ischemic Core

Chen,

Lee,

Michel

et al. 2024

JAMA Neurol

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ImportanceRecently, 6 randomized clinical trials—RESCUE-Japan-LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism—Japan Large Ischemic Core Trial), ANGEL-ASPECT (Trial of Endovascular Therapy for Acute Ischemic Stroke With Large Infarct), SELECT2 (Trial of Endovascular Thrombectomy for Large Ischemic Strokes), TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke), TENSION (Endovascular Thrombectomy for Acute Ischemic Stroke With Established Large Infarct), and LASTE (Large Stroke Therapy Evaluation)—have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for the treatment of patients with ischemic stroke, anterior-circulation large vessel occlusions, and large areas of ischemic changes defined as an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 5 or less. Overall, the results appeared to be positive, with 5 of the 6 trials meeting their primary efficacy end point, and 1 trial that was a near miss. However, questions remain regarding how these trial results should be interpreted and incorporated into routine clinical practice.ObservationsIn this narrative review and analysis of published trials, important nuances of the available clinical data were identified, and important areas of lingering uncertainty were highlighted, including the efficacy and safety of EVT for patients with a low ASPECTS score in late treatment windows and those with large core volumes. Also emphasized was the possibly important role of advanced neuroimaging modalities such as perfusion and magnetic resonance imaging when making EVT treatment decisions for select patients with low ASPECTS scores.Conclusions and RelevanceRecent trial data provide strong evidence that EVT is safe and effective for patients with anterior, large vessel–occlusion stroke and low ASPECTS scores who present within 6 hours from stroke onset. However, patient outcomes often remain poor despite EVT treatment. The efficacy and safety of EVT for patients with low ASPECTS scores who present beyond 6 hours of stroke onset remain uncertain, and the current trial data seem too scarce to justify forgoing advanced stroke imaging during this extended time window. Furthermore, the efficacy and safety of EVT for patients with large core volumes (100 mL or greater) or M2 occlusions (ie, occlusions of the second segment of the middle cerebral artery) remain uncertain. Future research to better identify patients likely to meaningfully respond to EVT is needed to further optimize the stroke triage process and health care resource utilization.

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Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

Cited by 9 publications

References 8 publications

Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes

Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes

Endovascular Therapy and Outcomes Among Patients With Very Large Ischemic Core Stroke

Endovascular Stroke Thrombectomy for Patients With Large Ischemic Core

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