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Mechanical Thrombectomy in Ischemic Stroke Patients With ASPECTS 0–5
Study Questions:
What are the outcomes of patients with anterior circulation large vessel ischemic stroke who have significant early ischemic changes (ASPECTS 0-5 [Alberta Stroke Program Early Computed Tomography Score]) on their presenting CT?
Methods:
This is an observational, registry-based study of patients who underwent mechanical thrombectomy for anterior circulation large vessel ischemic stroke. The primary outcome was a favorable clinical outcome (defined as a modified Rankin scale score of 0-3) at 90 days. Adverse outcomes included all-cause mortality at 90 days and symptomatic intracranial hemorrhage (sICH). Successful reperfusion was defined as TICI (Thrombolysis In Cerebral Infarction) 2B/3 flow.
Results:
In this registry, 237 patients presented with ASPECTS 0-5 (93 with ASPECTS 5 and 144 with ASPECTS 0-4) and 1,295 with ASPECTS 6-10. All patients underwent attempted mechanical thrombectomy. In patients with ASPECTS 0-5, TICI 2B/3 flow was achieved in 70%. Patients with ASPECTS 0-5 had about the same chance of a favorable clinical outcome (40.1%) as of death (40.9%) at 90 days.
After adjustment for potential confounders in patients with ASPECTS 0-5, successful reperfusion was associated with favorable clinical outcome (adjusted odds ratio [aOR], 5.53; 95% confidence interval [CI], 2.36–12.96), lower mortality (aOR, 0.18; 95% CI, 0.08–0.39), and lower sICH (aOR, 0.24; 95% CI, 0.06–0.89) compared to unsuccessful reperfusion. When limiting analysis to patients with ASPECTS 0-4, successful reperfusion was not associated with favorable clinical outcome (aOR, 2.59; 95% CI, 0.86-7.82) or reduced sICH (aOR, 0.29; 95% CI, 0.05-1.54), but was associated with reduced mortality (aOR, 0.17; 95% CI, 0.06-0.50). Rates of sICH were similar between patients with ASPECTS 0-5 and 6-10 (7.2% vs. 6.0%; p = 0.47).
Conclusions:
In anterior circulation large vessel ischemic stroke patients with ASPECTS 0-5 undergoing mechanical thrombectomy in this registry-based study, successful reperfusion (TICI 2B/3) was associated with a favorable clinical outcome compared to unsuccessful reperfusion (TICI 0-2A). The rate of sICH was not higher in patients with ASPECTS 0-5 compared to patients with ASPECTS 6-10.
Perspective:
Low ASPECTS was an exclusion criterion in the recent randomized controlled trials that demonstrated a role for mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusion; thus, the efficacy and safety of thrombectomy in these patients remain unclear. In this observational study of patients with ASPECTS 0-5, patients who underwent successful thrombectomy did better than patients with unsuccessful thrombectomy, a finding that indirectly argues for mechanical thrombectomy over medical management in these patients.
As the authors note, this study should be considered hypothesis-generating. Its main limitation is that only patients selected to undergo thrombectomy were included in the study (i.e., no control group of patients with ASPECTS 0-5 who were not selected to undergo thrombectomy). Patients selected for thrombectomy may represent a healthier group of patients with clinical/radiographic features that suggest they are more likely to benefit from thrombectomy (selection bias). Thus, this study cohort may not well represent the entire population of large vessel occlusion patients with ASPECTS 0-5.
The controlled TENSION trial (not yet recruiting) will randomize patients with ASPECTS 3-5 to mechanical thrombectomy versus medical management and should provide stronger evidence regarding the best care for these patients.
Keywords: Brain Ischemia, Cerebral Infarction, Coronary Occlusion, Infarction, Intracranial Hemorrhages, Reperfusion, Secondary Prevention, Stroke, Thrombectomy, Tomography, Vascular Diseases
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