While the study suggests endovascular therapy can expand its horizons, one expert points out that 70% of the patients still had some disability by 90 days.
Patients who present with acute ischemic stroke and a baseline ASPECTS of 5 or lower can still benefit from mechanical thrombectomy, according to a retrospective analysis published online recently ahead of print in the Journal of NeuroInterventional Surgery.
Several large-scale randomized clinical trials have demonstrated the benefits of mechanical thrombectomy for the treatment of acute ischemic stroke. “Unfortunately, real-world patients are not always the ideal ‘trial’ candidates for thrombectomy,” write Isabelle Mourand, MD (Gui de Chauliac Hospital, Montpellier, France), and colleagues. “Therefore, neurologists and interventional neuroradiologists are confronted daily with the decision to treat . . . patients with acute stroke and a large necrotic core admitted in the recanalization time window with an accessible thrombus for thrombectomy. For this situation, no therapeutic criteria guidelines are available.”
To test the potential of mechanical thrombectomy is less than ideal circumstances, the investigators reviewed 108 consecutive patients who presented with acute ischemic stroke and an ASPECTS ≤ 5 on diffusion-weighted imaging. Of these patients, 60 were treated with mechanical thrombectomy, including 34 who received simultaneous IV thrombolysis. Their outcomes were compared with those of 48 controls who were not eligible for reperfusion therapy.
Overall, TICI 2b-3 was achieved in 75% of the thrombectomy-treated patients. An mRS score of 0-2 at 90 days was achieved in a greater proportion of patients who underwent thrombectomy compared with controls. In addition, rates of hemicraniectomy and death at 90 days were both significantly lower among patients who underwent thrombectomy. Rates of symptomatic intracranial hemorrhage (sICH) were similar for both groups.
Outcomes at 90 Days in Patients With ASPECTS ≤ 5
|
|
Thrombectomy (n = 60) |
Controls (n = 48) |
P Value |
|
mRS 0-2 |
30% |
2.1% |
< 0.001 |
|
Hemicraniectomy |
3.3% |
22.9% |
0.002 |
|
Death |
25% |
47.9% |
0.01 |
|
sICH |
5% |
6.3% |
0.78 |
Subgroup analysis revealed that patients aged 70 years and younger had significantly better clinical outcomes with thrombectomy than did older patients (37.5% vs 10% had a 90-day mRS of 0-2; P = 0.02), regardless of baseline characteristics or recanalization rate.
According to Mayank Goyal, MD (University of Calgary, Calgary Alberta, Canada), who was not involved in the research, the study addresses an important issue—how to determine which patients are the best candidates for endovascular therapy.
“It brings to the limelight the fact that patients [with low ASPECTS] may have the potential for significant benefit by endovascular treatment,” he told Neurovascular Exchange. “It [also] leads us to think in that in that direction and address the topic in a more systematic fashion.”
Specifically, Goyal called for a large, randomized trial to overcome biases, such as the fact that patients treated endovascularly may receive a different level of aftercare as those treated medically.
In addition, it is important to consider cost-effectiveness, he said, pointing out that “70% of the patients did not have a good outcome, which means we are still treating a lot of patients who may not have that good an outcome.
“This study points us in the right direction. It tells us this topic is worth investigating, but it does not necessarily provide direction [regarding what] we should be doing from tomorrow onwards,” Goyal concluded.
Source:
Mourand I, Abergel E, Mantilla D, et al. Favorable revascularization therapy in patients with ASPECTS ≤ 5 on DWI in anterior circulation stroke. J NeuroInterv Surg. 2017;Epub ahead of print.
Disclosures:
- Mourand reports no relevant conflicts of interest.
- Goyal reports consulting for Medtronic, Stryker, Microvention, and Cerenovus.
