In a large Japanese registry study, the risk of symptomatic intracranial hemorrhage was not increased with an endovascular approach.
In patients with large vessel occlusion (LVO) stroke who have an ASPECTS ≤ 5, endovascular therapy may improve the likelihood of good functional outcome, according to data from a multicenter Japanese registry published online March 18, 2019, in Stroke.
Stroke patients with large ischemic cores are often excluded from randomized controlled trials of endovascular interventions, investigators led by Hiroto Kakita, MD (Hyogo College of Medicine, Nishinomiya, Japan), point out in their paper. Trials that have included such patients yielded equivocal or contradictory findings.
Current American Heart Association guidelines recommend endovascular therapy for patients with ASPECTS of 6 to 10, Kakita et al note. “In [the] real world, endovascular therapy is sometimes performed for the patients with ASPECTS 0 to 5 because even if the early ischemic change is wide, [it] may be effective if the penumbra area is wide,” they explain. “However, reperfusion therapy for patients with large ischemic core may increase the risk of intracranial hemorrhage.”
To further understand the efficacy of endovascular therapy in this population, Kakita and colleagues used the RESCUE-Japan Registry 2 to identify patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted imaging. Outcomes were evaluated for patients who did (n = 172) or did not (n = 332) receive endovascular therapy, with a primary endpoint of 90-day mRS ≤ 2. Those who did not received the therapy were more likely to be elderly, female, have poor prestroke mRS scores, high NIHSS scores, and low ASPECTS. They were also more likely to have late admission.
Treatment with endovascular therapy was associated with a greater likelihood of achieving a good functional outcome compared with no endovascular therapy (19.8 % vs 4.2 %; P < 0.0001), with an adjusted OR of 2.33 (95% CI 1.10-4.94).
“There has been a concern that hemorrhagic event is caused by endovascular therapy when the patients have large ischemic core,” the researchers point out, but here there were no differences between those who did and did not receive endovascular therapy with regard to the rate of symptomatic intracranial hemorrhage within 72 hours (3.7 % vs 4.9%; P = 0.55; adjusted OR 0.50; 95% CI 0.14-1.73).
“Our large prospective registry of acute LVO patients suggested that outcomes of patients with large ischemic core were usually poor, but the data suggested [endovascular therapy] may increase the likelihood of good functional outcomes,” conclude the authors. “It is necessary to elucidate effectiveness of [endovascular therapy] for those patients by RCTs in the near future.”
Kakita H, Yoshimura S, Uchida K, et al. Impact of endovascular therapy in patients with large ischemic core: subanalysis of Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2. Stroke. 2019;Epub ahead of print.
Kakita reports no relevant conflicts of interest.