Thrombectomy in Low ASPECTS: Infarct Volume & Neurological Outcomes

Abstract

Unpacking Thrombectomy in Low ASPECTS: The Interplay of Infarct Volume and Neurological Recovery

BACKGROUND:

 Recent pivotal trials have underscored the profound benefit of endovascular thrombectomy even in Acute Ischemic Stroke (AIS) patients presenting with a low Alberta Stroke Program Early CT Score (ASPECTS). Remarkably, these studies observed significantly improved functional outcomes despite considerable follow-up infarct volumes, prompting a re-evaluation of infarct volume's predictive role in imaging. This analysis aimed to decipher how much of thrombectomy's effect on functional outcomes is explained by  follow-up infarct volume and . the early neurological status in these challenging stroke cases.

METHODS:

The TENSION trial, a randomized study spanning from February 2018 to January 2023 across 41 stroke centers, enrolled 253 AIS patients with anterior circulation large vessel occlusion and an ASPECTS of 3 to 5. Patients were randomized to receive either endovascular thrombectomy plus medical treatment or medical treatment alone. This secondary as-treated analysis included all patients with complete relevant data. Our primary endpoint was the 90-day modified Rankin Scale score. We employed confounder-adjusted mediation analysis to quantify the proportion of the treatment effect on the 90-day modified Rankin Scale score explained by . 24-hour follow-up infarct volume and . 24-hour National Institutes of Health Stroke Scale scores.

RESULTS:

 Out of 188 included patients, 87 (46%) were female, with a median age of 72 (interquartile range, 63–79) years. The endovascular thrombectomy cohort showed a 20.5 (95% CI, 8.3–33.7) percentage point higher likelihood of achieving independent ambulation (modified Rankin Scale, 0–3) and a 24.2 (95% CI, 13.4–35.8) percentage point lower 90-day mortality compared to medical treatment alone. The reduction in 24-hour follow-up infarct volume accounted for 30% of the treatment's effect on functional outcomes, while the 24-hour National Institutes of Health Stroke Scale score explained a more substantial 61%.

CONCLUSIONS:

For AIS patients with low ASPECTS, infarct volume exhibited limited explanatory power for functional outcomes when compared to the early neurological status. The early neurological status likely offers a more comprehensive reflection of critical factors such as specific brain region involvement, the disruption of structural networks, and selective neuronal loss, all of which contribute significantly to post-stroke recovery

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