ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study

 What you consider a 'better outcome' is still failure by any survivors reckoning. 100% recovery is the only goal in stroke. WHEN THE HELL ARE YOU GOING TO ACTUALLY GET AROUND TO SOLVING STROKE? This chipping at the edges is barely helping.

ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study

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Stefania Nannoni*, Johannes Kaesmacher*, Federico Ricciardi, ...

First Published April 22, 2021 Research Article Find in PubMed 

https://doi.org/10.1177/17474930211009806

Article information

Abstract

Introduction

The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of endovascular treatment patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late endovascular treatment.

Methods

We retrospectively analyzed all consecutive acute ischemic stroke patients admitted 6–24 h after last proof of good health in two stroke centers, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS ≥ 10 and ASPECTS ≥ 7, or NIHSS ≥ 20 and ASPECTS ≥ 5. We assessed the interaction between the presence of the clinical-ASPECTS mismatch and late endovascular treatment using ordinal shift analysis of the three-month modified Rankin Scale and adjusting for multiple confounders.

Results

The included 337 patients had a median age of 73 years (IQR = 61–82), admission NIHSS of 18 (15–22), and baseline ASPECTS of 7 (5–9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late endovascular treatment. Among 141 (41.8%) mismatch negative patients, late endovascular treatment was performed in 72 (51.1%) patients. In the adjusted analysis, late endovascular treatment was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted odd ratio, aOR = 2.83; 95% confidence interval, CI: 1.48–5.58) but not in its absence (aOR = 1.32; 95%CI: 0.61–2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late endovascular treatment was 0.073.

Conclusions

In our retrospective two-site analysis, late endovascular treatment seemed effective(Since you didn't get to 100% recovery, in no sense of the word can it be considered effective.) in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late endovascular treatment decisions, obviating the need for advanced imaging.

Keywords Acute ischemic stroke, late time window, endovascular treatment, ASPECTS

Introduction

Recent randomized clinical trials have provided class I evidence for the efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients from proximal anterior circulation large vessel occlusion (LVO) in the late-time window, if properly selected based on their neuroimaging profile.^1–3 However, we previously demonstrated that the proportion of late-admitted AIS eligible for EVT according to strict trial criteria was low in the real-life scenario.⁴

Enlarging the selection criteria for late EVT could allow a larger population of AIS patients to benefit from the revascularization procedures. Notably, the use of a simpler neuroimaging protocol could help with the decision to proceed with mechanical thrombectomy in case of absent, failed or contraindicated advanced imaging, or in situations of discordant imaging profile.⁵

The Alberta Stroke Program Early CT Score (ASPECTS) is an easily applicable tool to estimate the amount of irreversibly damaged brain tissue in the middle cerebral artery (MCA) territory strokes.⁶ Originally designed for non-contrast CT scan (NCCT), it has been also applied to diffusion-weighted imaging (DWI) sequences, after one-point adjustment.⁷ However, the role of ASPECTS in selecting patients who are most likely to benefit from EVT is not clearly established in the late time window.^8,9 Also, to the best of our knowledge, its use in association of clinical stroke severity as a surrogate of the core-penumbra mismatch¹ has not been evaluated.

The main aim of our study was to analyze the clinical outcome of late-arriving AIS patients with proximal anterior circulation LVO depending on the presence of a clinical-ASPECTS mismatch and of treatment with mechanical thrombectomy in two comprehensive stroke centers.

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