Endovascular therapy not effective for severe occlusive stroke patients with ASPECTS 3 or less: JAMA

Japan: Researchers have found in a new study that Endovascular therapy is effective in less severe acute large vessel occlusive stroke with ASPECTS 4 to 5.

In patients with ASPECTS 3 or less, endovascular therapy (EVT) should be carefully scrutinized, considering the higher risk of symptomatic intracranial hemorrhage and a lower likelihood of returning to functional dependence study published in JAMA Neurology has stated.

The study showed that EVT improved 90-day functional outcomes in patients with acute large vessel occlusive stroke and ASPECTS was 4 to 5 but not in patients having ASPECTS 3 or less.

ASPECTS a CT-based measure for stroke assessment can help clinicians evaluate the scope of damage and determine whether the patient will benefit from endovascular treatment.

The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is a 10-point system makes evaluation of extent of the stroke by using data from a baseline noncontrast CT scan. It is a mortality predictor and its value correlates inversely with the severity and evolution of patients, confirming a good predictability with good specificity, sensitivity and area under the curve.The scores under 5 indicate a larger infarct area.

In patients with acute stroke due to large-vessel occlusion, endovascular therapy has been shown to reduce functional disability. However, the efficacy of EVT may be limited by the extent of the ischemic region, measured using Alberta Stroke Program Early Computed Tomography Scores (ASPECTS). Considering this, Kazutaka Uchida, Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan, and colleagues aimed to compare the safety and efficacy of EVT according to ASPECTS 3 or less vs. 4 to 5.

They addressed whether there is a difference in the efficacy of endovascular therapy (EVT) in patients with acute sizeable ischemic stroke between ASPECTS 3 or less vs. 4 to 5.

Adult patients with acute ischemic stroke with a large ischemic region, defined as ASPECTS 3 to 5 primarily determined by MRI, with occlusion site at the internal carotid artery or middle cerebral artery segment, were enrolled. The researchers performed an open-label randomized clinical trial -- RESCUE-Japan LIMIT (The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism—Japan Large Ischemic Core Trial), across 45 stroke centers in Japan. Among 203 patients, 202 were included in the original trial and secondary analysis, and 1 withdrew consent. The secondary analysis was performed in April 2022.

Patients were randomly assigned to endovascular therapy with medical therapy or medical therapy alone. The study's primary outcome was the Modified Rankin Scale (mRS) score at 90 days and symptomatic and any intracranial hemorrhage within 48 hours.

The study led to the following findings:

Among 202 patients, 52% had ASPECTS 3 or less (mean age, 76.7 years; 50.9% females) and 96 had ASPECTS 4 to 5 (mean age, 75.6 years; 37.5% female individuals).

Of patients with ASPECTS 3 or less, 21.4% in the EVT group and 18.0% in the no EVT group had an mRS score of 0 to 3 (odds ratio [OR], 1.24).

Of patients with ASPECTS 4 to 5, 43.2% in the EVT group and 7.7% in the no EVT group at 90 days had an mRS score of 0 to 3 (OR, 9.12).

In those with ASPECTS of 3 or less, the ordinal shift across the mRS scores range toward a better outcome was not significant (common OR, 1.56) but was necessary for those with ASPECTS 4 to 5 (common OR, 4.48).

The risk of intracranial hemorrhage was significantly increased in patients with ASPECTS 3 or less when EVT was conducted (OR, 4.14) and nonsignificantly increased in those with ASPECTS 4 to 5 (OR, 2.05).

"Considering the lower chance of returning to functional independence and the higher risk of symptomatic intracranial hemorrhage in ASPECTS 3 or fewer patients," the researchers wrote in their conclusion, "the findings in this study indicate that EVT for this subgroup should be carefully considered."

Reference:

Uchida K, Shindo S, Yoshimura S, et al. Association Between Alberta Stroke Program Early Computed Tomography Score and Efficacy and Safety Outcomes With Endovascular Therapy in Patients With Stroke From Large-Vessel Occlusion: A Secondary Analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism—Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT). JAMA Neurol. Published online October 10, 2022. doi:10.1001/jamaneurol.2022.3285