Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window

Almallouhi, Eyad; Kasab, Sami Al; Hubbard, Zachary; Bass, Eric; Porto, Guilherme; Alawieh, Ali; Chalhoub, Reda M; Jabbour, Pascal; Starke, Robert M.; Wolfe, Stacey Quintero; Arthur, Adam S; Samaniego, Edgar A; Maier, Ilko; Howard, Brian M.; Rai, Ansaar; Park, Min; Psychogios, Marios; Leacy, Reade De; Dumont, Travis M.; Levitt, Michael R.; Polifka, Adam; Osbun, Joshua W.; Crosa, Roberto; Kim, Joon‐Tae; Casagrande, Walter; Yoshimura, Shinichi; Matouk, Charles; Kan, Peter; Williamson, Richard; Gory, Benjamin; Mokin, Maxim; Fragata, Isabel; Zaidat, Osama O.; Yoo, Albert J.; Spiotta, Alejandro M; Peterson, Eric C.; Mocco, J; Fifi, Johanna T; Kellner, Christopher P.; El‐Ghanem, Mohammad; Fargen, Kyle M; Brown, Patrick; Tjoumakaris, Stavropoula; Gooch, M. Reid; Herial, Nabeel; Hoh, Brian L.; Chalouhi, Nohra; Goyal, Nitin; Hoit, Daniel; Rodriguez-Erazú, Fernanda; Liman, Jan; Limaye, Kaustubh; Cawley, C. Michael; Pradilla, Gustavo; Guerrero, Waldo R; Reis, João Carlos R.; Cerejo, Russell

doi:10.1001/jamanetworkopen.2021.37708

Cited by 39 publications

(28 citation statements)

References 32 publications

(96 reference statements)

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“…M1 occlusion was more frequent in the PTM group, while ICA was the major occlusion site in the non-PTM group (all but one were ICA terminus). This suggests that core growth with M1 occlusion was slower than that with ICA occlusion, which was consistent with the results in previous studies [7,16] Fig. 3 Modified Rankin Scale (mRS) at 3 months after stroke between the PTM and the non-PTM groups.…”

Section: Discussionsupporting

confidence: 90%

Ischemic Lesion Growth in Patients with a Persistent Target Mismatch After Large Vessel Occlusion

et al. 2022

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Background Failure to reperfuse a cerebral occlusion resulting in a persistent penumbral pattern has not been fully described. Methods We retrospectively reviewed patients with anterior large vessel occlusion who did not receive reperfusion, and underwent repeated perfusion imaging, with baseline imaging < 6 h after onset and follow-up scans from 16–168 h. A persistent target mismatch (PTM) was defined as core volume of < 100 mL, mismatch ratio > 1.2, and mismatch volume > 10 mL on follow-up imaging. Patients were divided into PTM or non-PTM groups. Ischemic core and penumbral volumes were compared between baseline and follow-up imaging between the two groups, and collateral flow status assessed using CT perfusion collateral index. Results A total of 25 patients (14 PTM and 11 non-PTM) were enrolled in the study. Median core volumes increased slightly in the PTM group, from 22 to 36 ml. There was a much greater increase in the non-PTM group, from 57 to 190 ml. Penumbral volumes were stable in the PTM group from a median of 79 ml at baseline to 88 ml at follow-up, whereas penumbra was reduced in the non-PTM group, from 120 to 0 ml. Collateral flow status was also better in the PTM group and the median collateral index was 33% compared with 44% in the non-PTM group (p = 0.043). Conclusion Multiple patients were identified with limited core growth and large penumbra (persistent target mismatch) > 16 h after stroke onset, likely due to more favorable collateral flow.

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Section: Discussionsupporting

confidence: 90%

Ischemic Lesion Growth in Patients with a Persistent Target Mismatch After Large Vessel Occlusion

et al. 2022

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“…After initial screening, we retrieved the full text of 68 records that were considered potentially eligible for inclusion, and after reading the full-text articles, 14 were further excluded (Supplemental eTable 2). Finally, we identified 24 eligible studies for inclusion, of which 1 was an individual patient data (IPD) meta-analysis of RCT-derived data conducted by the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) collaborators, 31 2 were RCTs not included in the previous meta-analysis, 32,33 16 were observational studies based on prospectively collected data (prospective registries), [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] and 5 were retrospective cohort studies (Table 1), [50][51][52][53][54] comprising a total of 2539 AIS patients with low ASPECTS score treated with EVT.…”

Section: Literature Search and Included Studiesmentioning

confidence: 99%

“…The risk of bias in the included observational studies was assessed by the ROBINS-I tool and is presented in Supplemental eFigures 3-4. Overall, 16 studies were not controlled; 34,35,[37][38][39][40][41]43,45,46,48,49,[51][52][53][54] therefore, the assessment of confounding bias, bias in the classification of intervention, and bias due to deviations from intended interventions were not applicable. Yet, significant confounding bias was detected in all five controlled studies as there were several baseline differences between the patients' groups (EVTtreated versus BMT-treated).…”

Section: Quality Control Of Included Studiesmentioning

confidence: 99%

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

Safouris

Palaiodimou

Szikora

et al. 2022

Ther Adv Neurol Disord

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Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0–5 has not yet proven safe and effective by clinical trials. Objectives: The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial. Design: Systematic review and meta-analysis of available studies in accordance with the PRISMA statement. Data sources and Methods: We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0–3 at 3 months, (2) mRS score 0–2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months. Results: Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0–5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0–3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0–2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0–3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71). Conclusion: EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients. Registration: The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.

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“…However, previous observational studies and the meta-analysis of HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) focusing on the early time window with a comparably small number of patients showed conflicting results regarding the association of EVT with functional outcomes . Currently, data on patients with extensive baseline stroke who also presented in the extended time window are sparse . For example, the median time from stroke onset to admission in the recently published RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Large Ischemic Core Trial) was 3 hours, with only 30% of patients presenting more than 6 hours after stroke onset …”

Section: Introductionmentioning

confidence: 99%

Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction

et al. 2022

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ImportanceOnly limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction.ObjectiveTo assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction.Design, Setting, and ParticipantsThis retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry–Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019.Main Outcomes and MeasuresThe primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis.InterventionEndovascular treatment.ResultsOf 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P &lt; .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P &lt; .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285).Conclusions and RelevanceIn this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.

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Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window

Cited by 39 publications

References 32 publications

Ischemic Lesion Growth in Patients with a Persistent Target Mismatch After Large Vessel Occlusion

Ischemic Lesion Growth in Patients with a Persistent Target Mismatch After Large Vessel Occlusion

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

Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction

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