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Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes
  1. Mehdi Bouslama1,
  2. Clara M Barreira2,
  3. Diogo C Haussen2,
  4. Gabriel Martins Rodrigues1,
  5. Leonardo Pisani3,
  6. Michael R Frankel1,
  7. Raul G Nogueira4
  1. 1Department of Neurology, Emory University, Atlanta, Georgia, USA
  2. 2Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
  3. 3Department of Radiology, Georgetown University Medical Center, Washington, District of Columbia, USA
  4. 4Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Dr Raul G Nogueira, Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, GA 30303, USA; rnoguei{at}


Background Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis.

Objective To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes.

Methods Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0–5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups.

Results 1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS.

Conclusions Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.

  • thrombectomy
  • stroke
  • intervention

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  • Twitter @bouslamamd, @diogohaussen, @pisanileonardo

  • MB and CMB contributed equally.

  • Contributors Study design: MB, CMB, RGN. Data collection, analysis, and interpretation: MB, CMB, DCH, GMR, LP, MRF, RGN. Drafting the original manuscript: MB. Revising the work critically for important intellectual content: MB, CMB, DCH, GMR, LP, MRF, RGN. Final approval: MB, CMB, DCH, GMR, LP, MRF, RGN. Agreement to be accountable for all aspects of the work: MB, CMB, DCH, GMR, LP, MRF, RGN.

  • 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 DCH reports consulting fees for advisory roles with Stryker, Cerenovus, Vesalio, and stock options with Viz-AI. MRF reports research funding from Nico Corp, Inc (ENRICH trial). RGN reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, Phenox, Prolong Pharmaceuticals, Stryker Neurovascular, and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, and Perfuze.

  • Patient consent for publication Not required.

  • Ethics approval ocal institutional review board (IRB)/Emory University IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The unpublished data from this dataset is held by Grady Memorial Hospital/Emory University and MB/RGN. Requests for data sharing would have to be discussed with them directly.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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