Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis

Abstract

The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

“…14 Better functional outcomes have been reported from another systematic review and meta-analysis (EVT: 28% versus 4% with BMT), with similar rates of mortality (EVT: 31% versus BMT: 37%) and sICH (EVT: 9% versus BMT: 6%). 15 Similar results have been reported from three other meta-analyses, assessing ASPECTS, pre-treatment infarct core volume, or both 16–18 (Supplemental eTable 1 ). Since the publication of these analyses, the experience from large multi-center registries and one randomized-controlled clinical trial (RCT) has been published, providing exciting new data on this subgroup of LVO AIS patients, justifying an updated systematic review and meta-analysis.…”

A differential detailed diffusion-weighted imaging-ASPECTS for cerebral infarct volume measurement and outcome prediction

“…For each of the defined regions, 1 point was subtracted for areas of hyperintensity on DWI. Unlike conventional DWI-ASPECTS, [12][13][14][15] in detailed DWI-ASPECTS 1 point was not subtracted if the hyperintensity on DWI was punctate or less than half of one-part area of M1-6. In cases where it was difficult to assess whether the hyperintensity area was more than half of the one-part area, 1 point was subtracted.…”

Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core (ANGEL-ASPECT): protocol of a multicentre randomised trial

“…Those who pass the exam (>80 points) will obtain the ASPECTS assessment qualification certificate and be qualified for imaging Box 1 Continued (8) Brain tumour (with mass effect). (9) The expected survival time is less than 1 year year (such as complicated with malignant tumour, serious heart and lung diseases).…”

“…Many studies showed benefit of thrombectomy for large infarct core volume defined by low ASPECTS or large CTP or ADC volume 3 7–10. Recently, the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism–Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT)11 showed patients with large infarct core (ASPECTS 3–5) benefits form EVT compared with medical management alone but EVT is associated with more intracranial haemorrhages (ICH).…”