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Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis

  • Jose Danilo B. Diestro (a1) (a2), Adam A. Dmytriw (a2), Gabriel Broocks (a3), Karen Chen (a4), Joshua A. Hirsch (a5), Andre Kemmling (a3), Kevin Phan (a6) (a7) and Aditya Bharatha (a1) (a2) (a8)...

Abstract:

Background:

The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6.

Objective:

We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less).

Methods:

Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only.

Results:

Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group.

Conclusions:

This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.

RÉSUMÉ :

La thrombectomie endovasculaire destinée à des patients victimes d’accident ischémique ayant obtenu de faibles scores à l’échelle ASPECTS pour ce qui est de l’occlusion de leurs grandes artères cérébrales.

Contexte:

Les lignes directrices actuelles de l’American Heart Association quant aux accidents ischémiques aigus considèrent que l’utilisation de la thrombectomie endovasculaire (TE) pour des patients ayant obtenu à l’échelle ASPECTS (Alberta Stroke Program Early CT Score) un score de ≥6 constitue une recommandation de niveau 1A, c’est-à-dire une forte recommandation.

Objectif:

Nous entendons déterminer la sécurité et l’efficacité de la TE pour des patients victimes d’un accident ischémique aigu qui ont obtenu, pour leurs grandes artères, un faible score à l’échelle ASPECTS (5 ou moins), laquelle constitue une mesure d’occlusion.

Méthodes:

Pour trouver des études évaluant l’efficacité de la TE chez ce type de patients, nous avons interrogé les bases de données suivantes : Medline, Cochrane Central Register of Controlled Trials et ClinicalTrials.gov. De plus, nous avons effectué une méta-analyse de proportions afin de comparer l’évolution de l’état clinique de patients ayant subi une TE à l’évolution de l’état clinique d’autres patients n’ayant reçu seulement que le meilleur traitement médical.

Résultats:

Au total, 9 études incluant 1 196 patients ont été retenues. Une tendance (p = 0,11) à un taux d’hémorragie intracérébrale symptomatique (HICS) plus élevée a été notée dans le groupe de patients ayant subi une TE (9,2 % ; IC 95 %, 6,1 % - 13,6 % ; I2 53,37 %) en comparaison avec l’autre groupe (5,5 % ; IC 95 %, 3,7 % - 8,1 % ; I2 = 0 %). Aucune différence n’a émergé (p = 0,41) entre le taux de mortalité combiné après 90 jours (pooled 90-day mortality) des patients ayant subi une TE (30,7 % ; IC 95 %, 21,7 – 41,5 % ; I2 84.23 %) et celui des autres patients (36,6 % ; IC 95 %, 26,4 % - 48,1% ; I2 76,2 %). Mentionnons enfin que les patients ayant bénéficié d’une TE ont donné à voir au bout de 90 jours (p = 0,001) une évolution plus satisfaisante de leur état clinique. En effet, 27,7 % d’entre eux (IC 95 %, 21,8 – 34,5 % ; I2 62,08 %) ont obtenu un score de 0 à 2 à l’échelle modifiée de Rankin alors qu’ils n’étaient seulement que 3,7 % (IC 95 %, 2,3 -5,9 % ; I2 87,21 %) dans l’autre groupe.

Conclusions:

Cette méta-analyse montre ainsi une tendance à des taux d’HICS plus élevés parmi des patients ayant subi une TE et ayant obtenu de faibles scores à l’échelle ASPECTS. Malgré cela, une proportion notable de ce sous-ensemble de patients a quand même obtenu au bout de 90 jours de bons résultats en termes de capacité fonctionnelle. Des essais cliniques randomisés demeurent nécessaires pour étayer cette constatation car un biais important est inhérent aux études observationnelles inclues dans cette étude.

Copyright

Corresponding author

Correspondence to: Jose Danilo B. Diestro MD, St. Michael’s Hospital, Medical Imaging Room CC3-141, 30 Bond Street, Toronto, ONM5B 1W8, Canada. Email: danni.diestro@gmail.com

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Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis

  • Jose Danilo B. Diestro (a1) (a2), Adam A. Dmytriw (a2), Gabriel Broocks (a3), Karen Chen (a4), Joshua A. Hirsch (a5), Andre Kemmling (a3), Kevin Phan (a6) (a7) and Aditya Bharatha (a1) (a2) (a8)...

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