Endovascular Therapy Might Benefit Stroke Patients with Large Ischemic Region

In the American Heart Association guideline 2018, endovascular therapy (EVT) has been strongly recommended as class of recommendation (COR) I for patients with acute cerebral large vessel occlusion (LVO), the Alberta Stroke Program Early CT Score (ASPECTS) 6 or more. The ASPECTS score has a scale of 1-10, with lower values indicating larger infarctions. However, the effect of EVT on patients with low ASPECTS remains unclear. Therefore, Dr. Shinichi Yoshimura and his team conducted a study to compare the effectiveness of endovascular treatment and medical treatment alone for acute large vessel occlusion patients with large ischemic core.

They conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by ASPECTS values of 3 to 5. They randomly assigned patients to receive endovascular therapy with medical care (n=101) or medical care alone (n=102) within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. They used alteplase (0.6 mg per kilogram of body weight) when appropriate in both groups. The major outcome assessed was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. They also assessed for a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours.

Key findings of the study were:

The authors concluded, "In a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages."

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