Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis

Abstract

ObjectiveTo analyze outcome and its predictors after endovascular treatment (ET) in stroke patients suffering from large vessel occlusion with large pre-treatment infarct cores defined by an Alberta Stroke Program Early CT Score (ASPECTS) <6.MethodsWe analyzed data from an industry-independent, multicenter, prospective registry (German Stroke Registry – Endovascular Treatment) which enrolled consecutive patients treated by ET (June 2015–April 2018) with different devices. Multivariate logistic regression analyses identified predictors of independent outcome (IO) defined as a modified Rankin Scale (mRS) 0–2, and mortality at 90 days in patients with ASPECTS <6.ResultsOf 1700 patients included in the analysis, 152 (8.9%) had a baseline ASPECTS <6. Of these, 33 patients (21.6%) achieved IO, and 68 (44.7%) were dead at 90 days. A lower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) were predictors of IO. Successful recanalization had the strongest association with IO (OR 7.0, 95% CI 1.8 to 26.8). Pre-treatment parameters predicting IO were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57 and 0.94). A higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.ConclusionsA substantial proportion of stroke patients with an ASPECTS <6 can achieve independence after thrombectomy, in particular, if they are younger, have only moderate baseline stroke symptoms, and no relevant pre-stroke disability. These results may encourage considering thrombectomy in low ASPECTS patients in clinical practice until randomized trials are available.

Endovascular Treatment of Acute Ischemic Stroke in Clinical Practice: Analysis of Workflow and Outcome in a Tertiary Care Center

“…The latter may be due to the difference in median ASPECTS on admission (9 vs. 7). Of note, both the German Stroke Registry Endovascular Treatment and our single-center registry indicate that patients with ASPECTS ≤ 6 can achieve a favorable outcome ( 26 ) ( Figure 4 ). This was also shown by a recent meta-analysis of seven randomized EVT trials ( 27 ).…”

Sex Differences in Outcome After Thrombectomy for Acute Ischemic Stroke are Explained by Confounding Factors

“…Notably, these parameters, i.e. age and prestroke functional impairment, are known predictors of outcome after EVT [ 20 , 21 ].…”

Endovascular Therapy for Patients With Large Ischemic Strokes

“…The results of this analysis of registry data add to a growing body of observational studies suggesting a potential benefit of EVT in patients with low ASPECTS. [5][6][7] Despite some differences in populations and outcomes, the main results are quite similar among these studies. In brief, outcome after EVT in patients with ASPECTS <6 is clearly worse than in those with ASPECTS 6 to 10.…”

“…These findings are in line with a recent analysis of EVT data from the large German stroke registry, which identified younger age and lower National Institutes of Health Stroke Scale at baseline as independent predictors of independent outcome in patients with low ASPECTS. 7 In the same perspective, the findings from a meta-analysis of the HERMES collaboration suggests that the combination of ischemic core volume with age and expected imaging-to-reperfusion time might improve prognosis assessment and guide EVT decisions. 14 Altogether, these data support individualized therapeutic decisions in the situation of lower ASPECTS with age as a key player, rather than an one size fits all approach.…”