Association Between Alberta Stroke Program Early Computed Tomography Score and Efficacy and Safety Outcomes With Endovascular Therapy in Patients With Stroke From Large-Vessel Occlusion

Abstract

ImportanceEndovascular therapy (EVT) has been found to reduce functional disability in patients with acute stroke due to large-vessel occlusion. However, the extent of the ischemic region, measured using Alberta Stroke Program Early Computed Tomography Scores, may limit the efficacy of EVT.ObjectiveTo compare the efficacy and safety of EVT according to ASPECTS 3 or less vs 4 to 5.Design, Setting, and ParticipantsThe Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism—Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT) was an open-label randomized clinical trial conducted from November 2018 to December 2021 at 45 stroke centers across Japan. The trial enrolled adult patients with acute ischemic stroke with a large ischemic region, defined as ASPECTS 3 to 5 primarily determined by magnetic resonance imaging, with occlusion site at the internal carotid artery or middle cerebral artery segment 1. Among 203 enrolled patients, 1 withdrew consent and 202 were included in the original trial and secondary analysis. This secondary analysis was conducted in April 2022.InterventionsPatients were randomly assigned to EVT with medical therapy or medical therapy alone.Main Outcomes and MeasuresModified Rankin Scale (mRS) score at 90 days and symptomatic and any intracranial hemorrhage within 48 hours.ResultsAmong 202 patients, 106 (52%) had ASPECTS 3 or less (mean [SD] age, 76.7 [9.6] years; 54 female individuals [50.9%]) and 96 had ASPECTS 4 to 5 (mean [SD] age, 75.6 [10.6] years; 36 female individuals [37.5%]). Of patients with ASPECTS 3 or less, 12 (21.4%) in the EVT group and 9 (18.0%) in the no EVT group had an mRS score of 0 to 3 (odds ratio [OR], 1.24; 95% CI, 0.47-3.26). Of patients with ASPECTS 4 to 5, 19 patients (43.2%) in the EVT group and 4 (7.7%) in the no EVT group had an mRS score of 0 to 3 at 90 days (OR, 9.12; 95% CI, 2.80-29.70; interaction P = .01). The ordinal shift across the range of mRS scores toward a better outcome was not significant in those with ASPECTS or 3 or less (common OR, 1.56; 95% CI, 0.79-3.10) but was significant in those with ASPECTS 4 to 5 (common OR, 4.48; 95% CI, 2.07-9.71; interaction P = .046). The risk of intracranial hemorrhage was significantly increased in patients with ASPECTS 3 or less when EVT was conducted (OR, 4.14; 95% CI, 1.84-9.32) and nonsignificantly increased in those with ASPECTS 4 to 5 (OR, 2.05; 95% CI, 0.89-4.73; interaction P = .24).Conclusions and RelevanceIn this study, EVT was associated with improved 90-day functional outcomes in patients with acute large vessel occlusive stroke and ASPECTS was 4 to 5 but not in those with ASPECTS 3 or less.Trial RegistrationClinicalTrials.gov Identifier: NCT03702413

Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct

“…As the RESCUE-Japan LIMIT trial, SELECT 2 trial, and TENSION trial excluded patients with LVO with baseline ASPECTS of 0 to 2, the ANGEL-ASPECT trial was, to our knowledge, the first RCT to investigate the effect of EVT in patients with LVO with ASPECTS of 0 to 2. The findings of this secondary analysis are concordant with a subgroup analysis of the RESCUE-Japan LIMIT trial, which demonstrated that EVT was associated with improved 90-day functional outcomes in patients with LVO with baseline ASPECTS of 4 to 5 but not in those with ASPECTS of 3 or less . However, the SELECT2 subgroup analysis suggests that patients with large ischemic core volume, defined as 70 mL or greater, 100 mL or greater, and 150 mL or greater, still derived benefit with EVT compared with medical management …”

Association of Time Course of Thrombectomy and Outcomes for Large Acute Ischemic Region: RESCUE-Japan LIMIT Sub-Analysis

“…19 In fact, a secondary analysis of RESCUE-Japan LIMIT revealed that EVT was associated with a significantly higher incidence of any ICH within 48 hours in patients with lower ASPECTS. 21 HERMES also showed that the incidence of symptomatic ICH after recanalization was four times higher in low ASPECTS cases compared with the medical treatment group. 22 However, the association of time course and ICH after reperfusion in patients with a large ischemic core has not been widely examined.…”

“…The small sample size prevented analysis of each ASPECTS category, but we recently showed in another sub-analysis that EVT is associated with improved outcomes in ASPECTS 4 to 5 cases but not in those with ASPECTS ≤3. 21 The association of time course and ASPECTS ≤3 is a future issue for consideration. We also note that DWI-MRI was the predominant imaging modality used to evaluate ASPECTS, and DWI-ASPECTS may be approximately one point lower than CT-ASPECTS.…”

Endovascular Thrombectomy in Patients With Very Low ASPECTS Scores

“…1-3 After reading the full texts of these 3 RCTs, one was excluded as it did not provide data for the subgroup of patients presenting with baseline ASPECTS scores between 0 and 2 (eFigure 1, links.lww.com/WNL/D124). 3,5 An attempt was made to collect aggregate data for patients with baseline ASPECTS scores between 0 and 2 from the RESCUE-Japan LIMIT and TESLA trials, which was not possible.…”

“…com/WNL/D124). 3,5 An attempt was made to collect aggregate data for patients with baseline ASPECTS scores between 0 and 2 from the RESCUE-Japan LIMIT and TESLA trials, which was not possible. Twenty of 352 (5.7%) and 62 of 456 (13.6%) total participants enrolled in SELECT2 and ANGEL-ASPECT, respectively, had baseline ASPECTS scores less than 3.…”