Solve the damn problem, don't just tell us it exists. Useless. The whole point of stroke research is to get survivors recovered. This did nothing to that goal.
Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis
Abstract
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(NOT GOOD ENOUGH! Solve the problem, don't give us weasel words!) 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.
Introduction
Acute
ischemic stroke (AIS) treatment aims at rapid reperfusion of oligemic
brain tissue, using two established recanalization therapies:
intravenous thrombolysis (IVT) and endovascular treatment (EVT).1
IVT has been shown to reduce disability in eligible AIS patients up to
4.5 h from symptom onset using standard neuroimaging and up to 9 h using
advanced neuroimaging.2 A main predictor of AIS outcome3 and treatment efficacy4
is infarct core volume at baseline. Baseline CT hypoattenuation of
greater than one-third of the middle cerebral artery (MCA) territory has
been an exclusion criterion for some – but not all – IVT clinical
trials and, according to most recent American Heart Association/
American Stroke Association (AHA/ASA) guidelines, no benefit from
thrombolytic treatment has been proven in this subgroup of AIS patients.5
The European Medicine Agency advises against treatment with alteplase
in ‘Patients with severe stroke’ [as assessed clinically (NIHSS
score > 2) or by appropriate imaging ] because ‘patients with very
severe stroke are at higher risk for intracerebral hemorrhage and
death’.6
European Stroke Organization (ESO) guidelines follow a different
approach, highlighting the fact that there is no evidence that extensive
ischemic changes on baseline imaging modify the treatment effect of
IVT.7,8
However, they note a significant interaction between the presence of
early ischemic changes on baseline CT and mortality after IVT treatment.
In conclusion, they provide a weak recommendation in favor of IVT based
on very low quality of evidence within 4.5 h from last seen well (LSW).9
As practically all AIS patients with large ischemic core suffer from
large-vessel occlusion (LVO), EVT can be used in conjunction with IVT or
as a standalone therapy in otherwise eligible large ischemic core
patients. However, patients with extensive infarcts at baseline were
excluded by many EVT clinical trials while international recommendations
advocate against EVT in LVO patients with low (<6) Alberta Stroke
Program Early Computed Tomography Score (ASPECTS).5,10
To
quantify the extent of hypodensities in baseline CT, ASPECTS has been
developed for anterior circulation LVO stroke [internal carotid artery
(ICA) or MCA).11
Focal hypoattenuation of the cortex and in the basal ganglia,
gray–white matter dedifferentiation and loss of the insular ribbon sign
are assessed through a 10-point scoring system corresponding to
anatomical regions that extend over the MCA arterial distribution: four
subcortical [caudate (C), lentiform (L), internal capsule (IC), insular
ribbon (I)] and six cortical areas spanning over the superficial MCA
territory (M1–M6).12
It was developed to quantify early ischemic changes (hypoattenuation,
loss of gray–white matter distinction, or focal swelling) on baseline CT
of AIS patients eligible for IVT arriving within 3 h from symptom
onset. For each region presenting early ischemic changes, the overall
score of 10 is reduced by 1. The goal was to develop practical
prediction tools of functional independence, dependence, and symptomatic
intracranial hemorrhage (sICH) after thrombolytic treatment. In the
seminal paper, ASPECTS < 8 almost excluded functional independence of
AIS patients post IVT, and ASPECTS showed inverse correlation with
mortality, reaching 50% for scores 0–2.11
ASPECTS never gained wide acceptance as a prognostic tool and failed to
substitute the exclusion criterion of hypodensity in more than
one-third of MCA territory for IVT. However, it gained momentum in the
clinical trials of EVT; most of the five first positive EVT trials used
an ASPECTS cut-off of 6 to include patients for randomization.10,13
Positive results led AHA/ASA and ESO guidelines to provide IA level
evidence for EVT in patients with an ASPECTS of 6 or greater.5,10
As a consequence, low ASPECTS is considered any score below 6,
corresponding to large core infarcts, for which there is currently no
strong recommendation for EVT.
A previous
meta-analysis of observational studies has indicated that EVT for low
ASPECTS is associated with improved functional independence and lower
mortality at 90 days without significant increase in sICH compared with
the best medical treatment (BMT), across various definitions, thresholds
of large core size, and time windows. EVT was associated with
significantly higher odds of functional independence (EVT: 25% versus BMT: 7%) and lower likelihood of mortality (EVT: 20% versus BMT: 30%) at 90 days, whereas the odds of sICH were similar (EVT: 9% versus BMT: 5%).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 both16–18 (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. The current meta-analysis differs from previously
published meta-analyses on the topic as we have excluded LVO patients
presenting with ASPECTS of 6, given the fact that EVT has a strong
recommendation (level 1/ grade A) for this specific LVO subgroup.
More at link.
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