Sishir Mannava, MD

Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, et al. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5. Stroke. 2019;50:880–888.

The goal for neurologists is ultimately to find ways to treat all stroke patients to some extent such that these patients are able to suffer less significant disability and have an opportunity to lead a full life. Patients who present with markers of early ischemic changes on initial CT brain often are unable to receive acute therapies if they present outside the 4.5-hour window for IV-tPA, or have a low ASPECTS score.

In an attempt to demonstrate benefit of acute endovascular reperfusion therapy in patients presenting with ASPECTS 0-5, Kaesmacher et al. studied the value of mechanical thrombectomy with SOLITAIRE FR device on functional outcomes, mortality, and symptomatic intracranial hemorrhage (sICH). Among patients included in the BEYOND-SWIFT registry, 237 patients had ASPECTS 0-5 and were included in the analysis. Patients presented with severe neurological deficits (median NIHSS 18), and successful reperfusion (TICI 2b or greater) was achieved in 69.9%. Patients who achieved successful reperfusion had significantly superior outcome than the patients who did not achieve successful reperfusion in all outcome variables. However, favorable outcome was defined as mRS 0-3 which is a deviation from traditional definitions of favorable outcome as mRS 0-2. This outcome was more often observed in those selected by MRI DWI-ASPECTS than patients selected by CT. When comparing those with low ASPECTS 0-5 to those with more favorable ASPECTS 6-10, the low ASPECTS patients had significantly lower rates of favorable outcome (mRS score, 0–3; 40.1% versus 61.2%; P<0.001) and a doubled mortality (40.9% versus 21.2%; P<0.001). Rates of symptomatic ICH were comparable between the two groups.

Overall, the authors found that in patients presenting with ASPECTS 0-5, successful reperfusion resulted in significantly superior outcomes as compared to unsuccessfully reperfused patients with similar ASPECTS score. Mortality benefit remained in those with ASPECTS 0-4, and rates of sICH were comparable between patients with low ASPECTS 0-5 to more favorable ASPECTS 6-10. This is significant, as such is a common fear regarding reperfusing a large infarct core.

In conclusion, although the authors offer some promising results, there were many limitations of this study, including: a lack of central adjudication for ASPECTS scoring; only endovascularly treated patients being included in this registry, possibly suggesting a selection bias; and only 1 device being used for revascularization. It is clear that future randomized controlled trials are needed to further elucidate the benefits of endovascular therapy for this low ASPECTS subpopulation, specifically in comparison to conservative medical management.