Objective To analyze outcome and its predictors after endovascular treatment (ET) in stroke patients suffering from large vessel occlusion with large pre-treatment infarct cores defined by an Alberta Stroke Program Early CT Score (ASPECTS) <6.
Methods We analyzed data from an industry-independent, multicenter, prospective registry (German Stroke Registry – Endovascular Treatment) which enrolled consecutive patients treated by ET (June 2015–April 2018) with different devices. Multivariate logistic regression analyses identified predictors of independent outcome (IO) defined as a modified Rankin Scale (mRS) 0–2, and mortality at 90 days in patients with ASPECTS <6.
Results Of 1700 patients included in the analysis, 152 (8.9%) had a baseline ASPECTS <6. Of these, 33 patients (21.6%) achieved IO, and 68 (44.7%) were dead at 90 days. A lower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) were predictors of IO. Successful recanalization had the strongest association with IO (OR 7.0, 95% CI 1.8 to 26.8). Pre-treatment parameters predicting IO were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57 and 0.94). A higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.
Conclusions A substantial proportion of stroke patients with an ASPECTS <6 can achieve independence after thrombectomy, in particular, if they are younger, have only moderate baseline stroke symptoms, and no relevant pre-stroke disability. These results may encourage considering thrombectomy in low ASPECTS patients in clinical practice until randomized trials are available.
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Contributors MD-C: Substantial contributions to the conception and design of the work. Acquisition, analysis and interpretation of data. Drafting the work and revising it critically for important intellectual content. HP, CB, JF: Analysis and interpretation of data. Revising the work critically for important intellectual content. FF, HL, GB, AA: Acquisition of data. Revising the work critically for important intellectual content. CG: Analysis and interpretation of data. Drafting the work and revising it critically for important intellectual content. GT: Substantial contributions to the conception and design of the work. Analysis and interpretation of data. Drafting the work and revising it critically for important intellectual content. All authors gave their final approval of the version published and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests AA reports honoraria as speaker from Bayer Vital. JF receives research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions- und Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; and serves as a consultant for Acandis, Boehringer Ingelheim, Cerenovus, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical. CG serves on scientific advisory boards for Bayer Vital, Boehringer Ingelheim, ActicorBiotech, Amgen, and Prediction Biosciences; has received funding for travel and/or speaker/ consulting honoraria from Bayer Vital, Boehringer Ingelheim, Sanofi Aventis, Amgen, EBS Technologies, GlaxoSmithKline, Lundbeck, Pfizer, Silk Road Medical, and UCB, and Abbott; serves on editorial boards for INFO Neurologie & Psychiatrie and Aktuelle Neurologie and as editor of the textbook Therapie und Verlauf neurologischer Erkrankungen; has received grants to supporting employees/ scientists of his clinic from Merz Pharmaceuticals, Allergan, Novartis, and NeuroConn; and receives research support from Deutsche Forschungsgesellschaft, the European Union, Wegener Foundation, Schilling Foundation, and Werner-Otto- Foundation. GT has received personal fees as consultant or lecturer from Acandis, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, Daichi Sankyo, Stryker, and research grants from Bayer, Federal Ministry for Economic Affairs and Energy (BMWi), Corona-Foundation, German Research Foundation (DFG), Else Kröner-Fresenius Foundation, European Union (Horizon 2020), German Innovation Fund.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. All data relevant to the study are included in the article.