Endovascular Therapy Might Benefit Stroke Patients with Large Ischemic Region
Endovascular therapy (ET) for acute ischemic stroke is now broadly recognized as one of the most powerful treatments. A recent study suggests that endovascular therapy benefits patients with strokes that have caused a larger area of ischemic damage. The study findings were published in The New England Journal of Medicine on February 09, 2022.
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:
- Upon analysis, the researchers found that the percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular therapy group and 12.7% in the medical-care group (relative risk, 2.43).
- They noted that the ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy.
- They observed an improvement of at least 8 points on the NIHSS score at 48 hours in 31.0% of the patients in the endovascular therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively.
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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