Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Safouris, Apostolos; Palaiodimou, Lina; Szikora, I; Kargiotis, Odysseas; Magoufis, Georgios; Psychogios, Klearchos; Paraskevas, George P.; Spiliοpoulos, Stavros; Brountzos, Elias; Nardai, Sándor; Goyal, Nitin; Sousa, Diana Aguiar de; Strbian, Daniel; Caso, Valeria; Alexandrov, Andrei V.; Tsivgoulis, Georgios

doi:10.1177/17562864221139632

Cited by 14 publications

(8 citation statements)

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“…Our results corroborate the findings from a previous systematic review and meta-analysis of randomized and observational studies suggesting no disparity in the beneficial effect of EVT between patients presenting with AS-PECTS scores 0-2 or 3-5. 6 Our finding contradicts a recently published post hoc analysis from the RESCUE-Japan LIMIT trial suggesting no benefit of EVT for patients with baseline ASPECTS scores of 3 or less, mainly detected and scored with MRI. 4 ASPECTS estimation with MRI is known to overestimate the ischemic core compared with ASPECTS calculation with CT. 7,8 This might have led to exclusion from participation in RESCUE-Japan LIMIT of patients who could have benefit from EVT.…”

Section: Discussioncontrasting

confidence: 99%

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Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

Katsanos,

Catanese,

Shoamanesh

2023

Neurology

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Background and Objectives:Randomized controlled trials (RCTs) have recently established the benefit of endovascular thrombectomy (EVT) in patients with large infarct core on baseline neuroimaging. We evaluated the utility of EVT in patients with very large infarct core, defined as Alberta Stroke Program Early CT scores (ASPECTS) of less than 3.Methods:We performed a systematic review and meta-analysis of the subgroups of patients with baseline ASPECTS scores 0-2 included in RCTs evaluating the utility of EVT in the setting of a large infarct core. The outcome of interest was the probability of three-month functional improvement assessed with the generalized odds ratios (ORs) of the modified Rankin Scale (mRS) scores between patients receiving EVT or medical management.Results:In the pooled analyses of 82 participants out of the total 808 (10%) enrolled in two individual trials we found a statistically significant shift in the distribution of mRS scores towards better outcomes in favor of EVT (generalized OR=1.46, 95%CI: 1.03, 2.07). No evidence of heterogeneity was detected (I2=0%; p for Cochran Q: 0.73).Discussion:The results from our pooled analysis challenge the exclusion of patients presenting with ASPECTS scores less than 3 from receiving EVT if they are otherwise eligible.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

Katsanos,

Catanese,

Shoamanesh

2023

Neurology

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“…Another factor with respect to the safety benefit of EVT in low ASPECTS patients could be related to the reduction of brain oedema and malignant mass effect, leading to reduced rates of decompressive hemicraniectomy. 22,23 An interesting point to note is that even in patients with a low ASPECTS thrombolysis was associated with good outcome contrary to the assumptions. (Figure 4) Although definite conclusions cannot be drawn from the present study in view of the analysis based on the relative risks and the absolute numbers and individual patient data was not available for knowing recanalization rates the study does provide some insights into safety of Intravenous Thrombolysis in this often excluded group of patients.…”

Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Effect of endovascular therapy in large anterior circulation ischaemic strokes: A systematic review and meta-analysis of randomised controlled trials

Panigrahi,

Thakur Hameer,

Bhatia

et al. 2023

European Stroke Journal

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Introduction: The benefit of endovascular treatment in large anterior circulation ischaemic strokes with low ASPECTS score (<6) is uncertain. Recent randomised studies have demonstrated the benefit of endovascular treatment (EVT) in large ischaemic strokes. The present meta-analysis aims to assess the combined effect of these studies on efficacy and safety of endovascular treatment in this group of patients. Materials and methods: We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases MEDLINE, PubMed, EMBASE, SCOPUS, Google Scholar, Tripdatabase were searched for randomised controlled trials with at least 50 participants from inception until February 16, 2023. The primary efficacy outcome analysed was the relative risk of functional independence defined as mRS – 0–2 at 90 days. Secondary efficacy outcomes included early neurological improvement, death due to any cause at 90 days and proportion of patients requiring decompressive hemicraniectomy. The primary safety outcome was the risk of developing symptomatic intracerebral haemorrhage (sICH). Results: A total of three studies (RESCUE Japan-LIMIT, SELECT 2 and ANGEL ASPECTS) involving 1011 patients; 510 in the EVT arm and 501 in the medical management (MM) arm met the defined criteria (ASPECTS-3-5). The combined RR for the primary outcome of mRS 0–2 was 2.53 [1.84–3.47] ( p = <0.0001) favouring EVT over MM. The primary safety outcome of sICH was not significant in the EVT arm with a combined RR of 1.84 [0.94–3.60] ( p = 0.5157). Mortality rates were similar in both arms (26.67% in EVT arm vs 27.94% in MM arm) with a combined RR of 0.95 [0.78; 1.16] ( p = 1.000). Conclusion: In patients with Large vessel occlusion (LVO) and low ASPECTS (3–5), EVT was associated with higher likelihood of achieving functional independence and early neurologic improvement but did not provide any mortality benefit.

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“…While there are a few systematic reviews evaluating EVT in AIS patients with large ischemic core volume, [20][21][22] this meta-anal- [7][8][9] Moreover, we aim to make this study a living systematic review and meta-analysis to include future RCTs comparing outcomes in AIS patients with large infarct regions who underwent EVT versus medical management only. Our systematic review adhered to full living systematic review methodology, used rigorous methods in screening regardless of language, assessed for certainty of evidence using the GRADE approach, and evaluated the risk of bias using the RoB 2 tool.…”

Section: Discussionmentioning

confidence: 99%

Endovascular Thrombectomy for Large Ischemic Strokes: A Living Systematic Review and Meta-Analysis of Randomized Trials

et al. 2023

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Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only.Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach.Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only.Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

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Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Cited by 14 publications

References 84 publications

Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

Effect of endovascular therapy in large anterior circulation ischaemic strokes: A systematic review and meta-analysis of randomised controlled trials

Endovascular Thrombectomy for Large Ischemic Strokes: A Living Systematic Review and Meta-Analysis of Randomized Trials

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