Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis

Phan, Kevin; Saleh, Serag; Dmytriw, Adam A; Maingard, Julian; Barras, Christen; Hirsch, Joshua A; Kok, Hong Kuan; Brooks, Mark; Chandra, Ronil V.; Asadi, Hamed

doi:10.1136/neurintsurg-2018-014250

Cited by 25 publications

(19 citation statements)

References 35 publications

(18 reference statements)

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“…Expectedly, our results are in line with previous studies [ 3 , 4 , 7 , 19 - 21 ] demonstrating the direct correlation between larger infarct core sizes decreased odds of favorable functional outcome. In our sample as a whole, for every 10 mL increase in core volume, there was a 22% increase in the risk of unfavorable outcome, and a 26% increase in the risk of 90 days functional dependence.…”

Section: Discussionsupporting

confidence: 93%

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

et al. 2020

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Background and Purpose Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.<br/>Methods This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0–3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).<br/>Results A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.<br/>Conclusions In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.

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Section: Discussionsupporting

confidence: 93%

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

et al. 2020

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“…A previous meta-analysis tackling the effect of ASPECTS on the outcomes of EVT patients suggested futility of the intervention for patients with low ASPECTS. 29 What our study reveals is that despite the relatively lower good (mRS of 0-2) 90-day outcomes (27.7%) compared to the earlier trials (46.0%) 13 utilizing criteria that screened out large core infarct patients, there is still benefit compared to low ASPECTS patients only receiving best medical therapy who have a dismal 3.7% rate of good outcomes at 90 days.…”

Section: Summary Of Evidencementioning

confidence: 56%

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

Diestro

Dmytriw

Broocks

et al. 2020

Can. J. Neurol. Sci.

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Background: The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6. Objective: We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less). Methods: Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only. Results: Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group. Conclusions: This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.

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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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Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis

Cited by 25 publications

References 35 publications

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

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

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