Introduction Intra-arterial (IA) therapy for large vessel occlusions (LVO) has been increasingly utilized to treat patients with acute stroke with high NIHSS. The size of pre-treatment infarct core has been linked to a higher rate of intracranial hemorrhage and worse clinical outcomes. Patients with ASPECTS scores >7 appear to have the best clinical outcomes. Whether the benefits of endovascular reperfusion can be extended to patients with lower ASPECTS remains to be studied. We sought to determine the clinical outcomes in patients with LVO who presented with ASPECTS of 5–7.

Materials and methods A retrospective chart review was performed on patients with LVO who presented to Grady Memorial Hospital and University of Pittsburgh Medical Center between 2009 and 2011. LVO was defined as extracranial/ intracranial internal carotid artery (ICA), M1 middle cerebral artery (MCA) or M2 MCA identified by CT, MR or conventional angiography. Patients with ASPECTS 5–7 on pre-treatment CT were included in the analysis. Demographic, clinical and radiographic variables were assessed. Symptomatic hemorrhage was defined as PH2 hemorrhage based on the ECASS definition. Successful reperfusion was defined as TICI 2A or greater. A good clinical outcome was defined as 90-day mRS of 0–2 while acceptable outcome was defined as mRS of 0–3. Infarct volume was tabulated with summation of the regions of interest around the final infarct on a CT or MRI obtained more than 24 h after the procedure.

Results A total of 76 patients were identified (mean age 66±13 years, mean NIHSS 20±6.) Fifty patients (66%) were transferred from an outside hospital and 34 (45%) received IV tPA prior to endovascular therapy. Successful reperfusion was achieved in 43 patients (57%). Symptomatic hemorrhages occurred in nine patients (12%) while asymptomatic hemorrhages were noted in 29 (38%) patients. Fourteen patients (18%) achieved a good clinical outcome while 23 (30%) achieved an acceptable outcome. The median final infarct volume was 90 cm³ (IQR 49-155 cm³). Patients with successful reperfusion were more likely to achieve a good clinical outcome (26% vs 9%, p<0.045) and acceptable clinical outcome (40% vs 12%, p<0.03).

Conclusions Despite the low probability of achieving good clinical outcome in patients with ASPECTS 5–7 who underwent IA therapy, successful revascularization still results in less disability when compared to non-reperfused patients. Therefore, IA therapy may be a reasonable option in patients and families who favor a shift from severe to moderate disability. Further larger prospective studies are warranted to confirm these results.

Competing interests A Noorian: None. S Rangaraju: None. K Owada: None. T Jovin: None. B Glenn: None. S Belagaje: None. A Anderson: None. F Nahab: None. M Frankel: None. R Nogueira: Concentric Medical, ev3 Neurovascular, CoAxia, and Rapid Medical. R Gupta: Concentric Medical, Codman Neurovascular, CoAxia, and Rapid Medical.