Impact of Endovascular Therapy in Patients With Large Ischemic Core

Abstract

Background and Purpose— Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core. Methods— Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days. Result— Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73). Conclusions— Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

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

“…All were observational studies utilizing prospectively collected stroke registry data. Apart from the study by Kakita et al, 25 all the included studies were retrospective. Four of the nine studies compared low ASPECTS patients undergoing EVT and best medical therapy.…”

“…Both groups are similar in all baseline characteristics, except for more females in the best medical therapy group (49.3% vs 41.8%, p = 0.047) and more diabetic patients in the best medical therapy group (37.3% vs 17.7%, p = 0.007). Of the four studies that indicated the median ASPECTS, two studies 25,34 had significantly lower ASPECTS in the best medical therapy group (ASPECTS 3) compared to the EVT group (ASPECTS 5). There were more distal middle cerebral artery (M2 segment) occlusions in the best medical therapy group compared to the EVT group (15.4% vs 5.4%, p = 0.04).…”

Incomplete or failed thrombectomy in acute stroke patients with Alberta Stroke Program Early Computed Tomography Score 0–5 – how harmful is trying?

“…HERMES, as well as other studies that suggested a benefit of MT in low ASPECTS cohorts, treated patients based on heterogeneous imaging protocols with evidence suggesting that the positive results were driven by magnetic resonance imaging selection [1,4,5,13]. Since CT is by far the most common modality to select patients for MT in the real-world setting, concern was raised that these findings might not be applicable with CT-based selection [14].…”

“…Evidence from randomized clinical trials supporting the benefit of mechanical thrombectomy (MT) in patients presenting with large ischaemic cores on admission [Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≤ 5] is not yet available. Currently, the best available evidence is derived from retrospective studies, which are suggestive of a possible treatment effect, as well as procedural safety [1][2][3][4][5][6]. Pivotal thrombectomy studies have demonstrated the association of recanalization with outcome showing that, in cases of failed MT, only~20% of patients reach functional independence [7].…”

Effect of workflow metrics on clinical outcomes of low diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) patients subjected to mechanical thrombectomy

“…Current guidelines note reservations regarding the benefits from thrombectomy for a subgroup of patients with Alberta Stroke Program Early Computed Tomography Score (ASPECTS) <6 since they were mostly excluded from recent randomized trials 2–7. Nonetheless, evidence from the HERMES study and retrospective multicentric studies supports the benefit of mechanical thrombectomy (MT) for this population whose prognosis would be otherwise dismal 8–15. Successful recanalization and baseline ischemic lesion volume measured by either ASPECTS score or volumetrically have consistently been reported as independent predictors of outcome, along with other factors such as age 9–12.…”