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

Broocks, Gabriel; Flottmann, Fabian; Schönfeld, Michael; Bechstein, Matthias; Aye, Pauline; Kniep, Helge; Faizy, Tobias D.; McDonough, Rosalie; Schön, Gerhard; Deb‐Chatterji, Milani; Thomalla, Götz; Sporns, Peter; Fiehler, Jens; Hanning, Uta; Kemmling, André; Meyer, Lukas

doi:10.1111/ene.14358

Cited by 17 publications

(22 citation statements)

References 14 publications

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“…Among 1166 studies obtained, finally 14 studies with 2547 patients fulfilled our eligibility criteria (Figure 1). Of the total 14 studies consisting of 19 trials, 11 studies were cohort studies (2 obtained 7 scores in NOS, 14,15 5 obtained 8 scores in NOS 16–20 and 4 obtained 9 scores in NOS 8,21–23 ) 1 study 24 was matched case-control study (9 scores in NOS) and the remaining 2 were secondary analysis of 7 randomized controlled trials. 6,7 The study characteristics were shown in Table 1.…”

Section: Resultsmentioning

confidence: 99%

“…The selected studies were conducted between 2016 and 2020 with the sample size ranging from 56 to 743. Overall, 9 studies 7,15–19,21–23 considered large ischemic core as low aspects and 3 studies 6,14,24 regarded it as large core volume, along with 2 studies 8,20 defined it as low aspects and/or large core volume (Table 1). In addition, 3 studies 8,18,23 used NCCT to evaluate ASPECTS, 3 studies 19–21 used DWI, 2 studies 7,22 used NCCT or DWI,1 study 16 used CBV, 1 study 15 used CTASI, and one study had no clear definition to it.…”

Section: Resultsmentioning

confidence: 99%

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Mechanical thrombectomy versus medical care alone in large ischemic core: An up-to-date meta-analysis

Jiang

Wang

et al. 2021

Interv Neuroradiol

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Objective We compared outcomes and adverse events of thrombectomy versus medical management in acute ischemic stroke (AIS) patients with baseline large infarct core. Methods We searched Ovid MEDLINE(R) ALL, Cochrane Library Clinical Controlled Trials and EMBASE from inception to January 2021 for studies comparing thrombectomy and medical management alone in AIS patients who had ASPECTS <=7 or ischemic core volume >=50 ml. Imaging modalities to valuate ASPECTS and core volume were without restriction. The functional outcome was measured by mRS (modified Rankin Scale) score 0-2 at 90 days or discharge. The safety end point included the rates of mortality and sICH (symptomatic intracranial hemorrhage) or PH2 (parenchymal hematoma type 2). Results Fourteen studies with a total of 2547 patients (thrombectomy n = [1197]; medical care alone [n = 1350]) fulfilled our criteria. As for patients with low ASPECTS, pooled results indicated a higher odds of good functional outcome (OR = 3.47; 95% CI 1.99 to 6.07; P < 0.0001, I2=66%) and a lower risk of mortality (OR = 0.62; 95% CI 0.46 to 0.83; P = 0.001, I2=32%) in thrombectomy group compared with no thrombectomy group, but the risk of sICH or PH2 did not differ between two groups. As for patients with large core volume, both functional outcome and safety end point between two groups showed no statistically significant difference. Conclusion Thrombectomy remained safe and effective by careful selection in patients with low ASPECTS. More studies were warranted to explore contraindications for mechanical thrombectomy in AIS patients, especially in patients with large core volume.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Mechanical thrombectomy versus medical care alone in large ischemic core: An up-to-date meta-analysis

Jiang

Wang

et al. 2021

Interv Neuroradiol

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“…However, nonrandomized studies and meta-analyses evaluating the clinical benefit of MT in patients with low ASPECTS have mixed results, with some studies demonstrating improvement after MT even in patients with incomplete or failed recanalization, while others suggest MT is not beneficial in patients with low ASPECTS. 13 , 22 – 25 …”

Section: Discussionmentioning

confidence: 99%

Impact of Age and Alberta Stroke Program Early Computed Tomography Score 0 to 5 on Mechanical Thrombectomy Outcomes: Analysis From the STRATIS Registry

Zaidat

Liebeskind

Jadhav

et al. 2021

Stroke

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Background and Purpose: This study investigates clinical outcomes after mechanical thrombectomy in adult patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) of 0 to 5. Methods: We included data from the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) from patients who underwent mechanical thrombectomy within 8 hours of symptom onset and had available ASPECTS data adjudicated by an independent core laboratory. Angiographic and clinical outcomes were collected, including successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b), functional independence (modified Rankin Scale score 0–2), 90-day mortality, and symptomatic intracranial hemorrhage at 24 hours. Outcomes were stratified by ASPECTS scores and age. Results: Of the 984 patients enrolled, 763 had available ASPECTS data. Of these patients, 57 had ASPECTS of 0 to 5 with a median age of 63 years (interquartile range, 28–100), whereas 706 patients had ASPECTS of 6 to 10 with a median age of 70 years of age (interquartile range, 19–100). Ten patients had ASPECTS of 0 to 3 and 47 patients had ASPECTS of 4 to 5 at baseline. Successful reperfusion was achieved in 85.5% (47/55) in the ASPECTS of 0 to 5 group. Functional independence was achieved in 28.8% (15/52) in the ASPECTS of 0 to 5 versus 59.7% (388/650) in the 6 to 10 group ( P <0.001). Mortality rates were 30.8% (16/52) in the ASPECTS of 0 to 5 and 13.4% (87/650) in the 6 to 10 group ( P <0.001). sICH rates were 7.0% (4/57) in the ASPECTS of 0 to 5 and 0.9% (6/682) in the 6 to 10 group ( P <0.001). No patients aged >75 years with ASPECTS of 0 to 5 (0/12) achieved functional independence versus 44.8% (13/29) of those age ≤65 ( P =0.005). Conclusions: Patients <65 years of age with large core infarction (ASPECTS 0–5) have better rates of functional independence and lower rates of mortality compared with patients >75 years of age. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239640.

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“…Good and very poor functional outcomes were defined as mRS 0-2 and mRS 5-6, respectively. [16][17][18][19][20] The mRS was evaluated at the 90-day follow-up by a physician or a trained and certified mRS nurse. sICH was defined according to the second European-Australasian Acute Stroke Study (ECASS II) as presence of intracerebral hemorrhage and a four-point neurological deterioration on the NIHSS.…”

Section: Study Cohortmentioning

confidence: 99%

“…The median ASPECTS was 4 (IQR 3-5), the median time from symptom onset to imaging was 119 min (IQR 79-157 min), and the median NIHSS was 18 (IQR [15][16][17][18][19][20][21][22]. A total of 290 patients (68%) received IVT and 168 patients (39%) underwent MT.…”

Section: Study Cohortmentioning

confidence: 99%

Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS

Broocks

McDonough

Bechstein

et al. 2022

J NeuroIntervent Surg

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BackgroundThe benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT.MethodsThis multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH).Results429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome.ConclusionsBridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.

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

Cited by 17 publications

References 14 publications

Mechanical thrombectomy versus medical care alone in large ischemic core: An up-to-date meta-analysis

Mechanical thrombectomy versus medical care alone in large ischemic core: An up-to-date meta-analysis

Impact of Age and Alberta Stroke Program Early Computed Tomography Score 0 to 5 on Mechanical Thrombectomy Outcomes: Analysis From the STRATIS Registry

Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS

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