Mechanical Thrombectomy in Anterior Circulation Occlusion Could Be More Effective than Medical Management Even in Low DWI-ASPECTS Patients

Ohta, Tsuyoshi; Morimoto, Masanori; Okada, Kenji; Fukuda, M; Onishi, Hirokazu; Masahira, Noritaka; Matsuoka, Toshifumi; Takaya, Tomofumi; Takemura, Mitsuhiro

doi:10.2176/nmc.oa.2017-0203

Cited by 26 publications

(23 citation statements)

References 48 publications

(53 reference statements)

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“…Overall, 1194 patients (cases) underwent MT (stent retriever, aspiration-first thrombectomy or combined techniques), whereas 184 patients (controls) were treated with medical therapy (IVT for eligible patients or conservative management). Five studies16–20 compared outcomes between the MT group and the medical treatment group whereas 12 studies21–32 reported series of patients with low ASPECTS exclusively treated with MT.…”

Section: Resultsmentioning

confidence: 99%

“…Nine studies were retrospective series17–19 23 25 27–30 and eight studies had a prospective design 16 20–22 24 26 31 32. Two included series were prospective randomized trials 16 20.…”

Section: Resultsmentioning

confidence: 99%

“…Two included series were prospective randomized trials 16 20. Overall, 11 articles (prospective studies16 20–22 24 26 31 32 and series with cases and controls16–19) were rated as high-quality studies based on the Newcastle–Ottawa quality assessment criteria (see online supplemental table 3).…”

Section: Resultsmentioning

confidence: 99%

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Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis

Cagnazzo

Derraz

Dargazanli

et al. 2019

J NeuroIntervent Surg

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BackgroundIt is uncertain whether mechanical thrombectomy (MT) increases the probability of a good outcome (modified Rankin Scale (mRS) 0–2) in patients with Alberta Stroke Program Early CT Score (ASPECTS) 0–6.ObjectiveTo assess the impact of MT in patients with pretreatment ASPECTS 0–6.MethodsAccording to PRISMA guidelines, we performed a systematic search of three databases for series of patients with ASPECTS 0–6 treated by MT. Random-effects meta-analysis was used to pool the following: rate of mRS 0–2 at 3 months follow-up, symptomatic intracranial hemorrhage (sICH), and mortality rates.ResultsWe included 17 studies and 1378 patients with ASPECTS 0–6 (1194 MT, 184 medical management). The rate of mRS 0–2 was 30.1% and 3.2% after MT and medical management, respectively. MT gave higher odds of mRS 0–2 (OR 4.76, p=0.01). Patients with ASPECTS 6 and 5 had comparable rates of good outcome (37.7% and 33.3%, respectively). Overall, the rate of mRS 0–2 was 17.1% in patients with ASPECTS 0–4: 22.1% and 13.9% of patients with ASPECTS 4 and 0–3 were functionally independent, respectively. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b–3) gave higher odds of mRS 0–2 than unsuccessful reperfusion (OR 5.2, p=0.001). The MT group tended to have lower odds of sICH compared with the controls (OR 0.48, p=0.06). Patients aged <70 years had higher rates of mRS 0–2 than those aged >70 years (40.3% vs 16.2%).ConclusionsPatients with ASPECTS 0–6may benefit from MT. Successful reperfusion increases the probability of 3-month functional independence without increasing the risk of sICH. Patients with ASPECTS 5 and 6 have comparable outcomes. MT can still enable approximately one in four patients with ASPECTS 4 to be independent, whereas only 14% of subjects with ASPECTS 0–3 regain a good functional outcome.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis

Cagnazzo

Derraz

Dargazanli

et al. 2019

J NeuroIntervent Surg

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“…Their findings unanimously suggest that this subgroup of patients may have benefit comparable to those with higher ASPECTS. Ohta et al 18 demonstrated that this benefit is even more apparent when these low ASPECTS patients undergoing EVT are compared to a group who receive medical therapy alone. The strongest evidence comes from a subgroup analysis of a randomized controlled trial (THRACE) that showed a favorable trend (36% vs 26%) toward good (0-2) 90-day mRS in patients who undergo EVT and intravenous thrombolysis compared to those receiving intravenous thrombolysis only for patients with ASPECTS of 0-4.…”

Section: Introductionmentioning

confidence: 99%

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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“…In addition, several studies have recently reported that the prognosis of mechanical thrombectomy is superior to that of medical treatment alone in patients with a low DWI-pc-ASPECTS score in the anterior circulation. [16][17][18] However, the characteristics and prognosis of acute BAO in patients with DWI-pc-ASPECTS of less than 6 have not been studied. Thus, we aimed to investigate the clinical characteristics and predictive prognostic factors for better clinical outcomes in acute BAO patients with DWI-pc-ASPECTS of less than 6 who underwent ERT.…”

Section: Introductionmentioning

confidence: 99%

DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome?

et al. 2019

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Background and purpose The prognosis of patients with acute basilar arterial occlusion after endovascular reperfusion therapy with diffusion-weighted imaging – posterior circulation–Alberta Stroke Program Early Computed Tomography Score (DWI-pc-ASPECTS) of 6 or less remains unclear. We aimed to assess the characteristics and prognosis of endovascular reperfusion therapy in patients with acute basilar arterial occlusion and DWI-pc-ASPECTS of 6 or less. Methods We analysed data collected from 1 January 2012 to 31 January 2018 in a prospective neuro-interventional registry of consecutive patients treated with endovascular reperfusion therapy. Clinical and imaging data on patients with DWI-pc-ASPECTS of 6 or less who underwent endovascular reperfusion therapy for acute basilar arterial occlusion were collected for this study. A good clinical outcome was defined as a modified Rankin scale of 2 or less at 90 days. Results Forty-five acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less were included. Among them, 11 (24.4%) patients had a good clinical outcome at 90 days. Patients with a good clinical outcome had less severe neurological symptoms at presentation (National Institutes of Health Stroke Scale (NIHSS) 19.0 (12.0–25.0) vs. 8.0 (6.0–11.5); P = 0.003) and were younger (72.5 years (57.0–80.0 years) vs. 63.0 years (55.5–69.0 years), P = 0.096) than those with a poor clinical outcome. The symptomatic intracranial haemorrhage rate was significantly higher in the poor clinical outcome group (13 (38.2%)) than in the good clinical outcome group (0 (0.0%)) ( P = 0.045). In particular, in patients aged over 70 years, a favourable outcome was low (18 (52.9%) vs. 1 (9.1%); P = 0.027) even after successful recanalisation. In a multivariate model, a low initial NIHSS score (odds ratio 1.21; 95% confidence interval 1.07–1.44; P = 0.0093) and age over 70 years (odds ratio 15.27; 95% confidence interval 1.85–379.79; P = 0.0321) were independent predictors of poor clinical outcome. Conclusions Even with DWI-pc-ASPECTS of 6 or less, good clinical outcome can be achieved after endovascular reperfusion therapy. Relatively mild initial symptoms and younger age can predict a better outcome in acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less.

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Mechanical Thrombectomy in Anterior Circulation Occlusion Could Be More Effective than Medical Management Even in Low DWI-ASPECTS Patients

Cited by 26 publications

References 48 publications

Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis

Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis

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

DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome?

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