Thrombectomy, but not thrombolysis, was associated with improved functional outcomes in patients with ASPECTS scores below 6.
Endovascular therapy might have a role to play in patients with acute ischemic strokes and low ASPECTS scores, according to hints from a small, retrospective analysis published recently online in the Journal of Neurosurgery.
Among patients with an ASPECTS score below 6, thrombectomy was associated with improved functional and symptomatic outcomes compared with conventional treatment that did not include either thrombectomy or thrombolysis, although it was accompanied by a higher risk of symptomatic intracranial hemorrhage (sICH), researchers led by Shaowei Jiang, MD (Xinhua Hospital, Shanghai, China), report.
“This strongly [indicates] that endovascular thrombectomy might be beneficial for improving the outcomes of patients with acute ischemic stroke and large infarcts,” they write.
Thrombolysis, on the other hand, was not associated with any advantages over conventional treatment, and like thrombectomy, carried a higher risk of sICH.
The ASPECTS score is considered to be a useful grading system for CT images obtained from patients with acute ischemic stroke, and current US guidelines include an ASPECTS ≥ 6 as one of the selection criteria for mechanical thrombectomy with a stent retriever. The guidance also notes that thrombectomy may be reasonable in patients with lower ASPECTS scores, although the benefits are uncertain in this group, which has largely been excluded from recent trials.
In the current study, Jiang et al retrospectively analyzed data on 89 patients hospitalized with moderately severe to severe acute ischemic strokes at two Chinese stroke centers. All patients were younger than 80 and had an anterior artery occlusion, an ASPECTS score below 6, and an NIHSS score of 10 or greater. Twenty-one patients were treated with thrombolysis with alteplase, 36 with thrombectomy using a stent retriever, and 32 with conventional treatment, which included anticoagulation for those without intracranial hemorrhage and lipid-lowering medication.
At 3 months, the rate of functional independence—mRS score 0-2—was significantly higher in patients who received thrombectomy than in those who received conventional treatment (17% vs 0; P = 0.026). Thrombectomy was also associated with greater odds of having a clinical improvement and of having a marked clinical improvement, defined by changes in NIHSS score from admission to discharge of at least 4 and 10 points, respectively.
Functional and symptomatic improvement did not differ between the thrombolysis and conventional treatment groups.
The mortality rate was not significantly different between the thrombectomy (33%), thrombolysis (48%), and conventional treatment (41%) groups, but sICH was elevated at 24 hours with both thrombectomy and thrombolysis—19% for both groups compared with 0 in the conventional arm (P < 0.05 for both).
The authors point out that the lack of benefit seen with thrombolysis is consistent with prior studies showing that a low ASPECTS score is an independent predictor of poor outcomes after IV thrombolysis.
“This finding supports the idea that patients with ASPECTS 0–5 would hardly benefit from alteplase injection,” they write. “Therefore, endovascular thrombectomy appears to be the only feasible therapy for managing patients with acute ischemic stroke and unfavorable ASPECTS (< 6) to achieve good outcome.”
Source:
Jiang S, Peng Y, Jing C-H, et al. Endovascular thrombectomy can be beneficial to acute ischemic stroke patients with large infarcts. J Neurosurg. 2018;Epub ahead of print.
Disclosures:
- The study was supported by a 2013-2014 National Clinical Key Specialty Construction Project, Key Issues in Emergency and Pre-Hospital Emergency Medical Hospital Cohesion, Integration of Severe Trauma Hospital Treatment Technology Research and Promotion, and the National Natural Science Foundation of China.
- Jiang reports no relevant conflicts of interest.
