Yoshimura S, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022

https://www.nejm.org/doi/full/10.1056/NEJMoa2118191

Abstract

Background: Endovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied.

Methods: We conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours.

Results: A total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P=0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001).

Conclusions: In a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages.

Comments of Dr. T. Sonia

So far large infarcts with low ASPECSTS scores (<6) were not considered for aggressive management.

More changes:

ASPECTS (Alberta Stroke Programme Early CT Score) is actually a CT score; however, in this study DWI MRI has been used for calculation; this is a huge change. As mentioned by the authors, the score will definitely be less, suggesting a larger infarction.

Other very important point is- from 6-24 hrs, FLAIR MRI is used in the absence of CT perfusion scan; this too has a lot of practical implications as many centres lack perfusion scan. This way many more stroke patients will benefit from intervention.

Dr.-T.-Soniya

Dr. T. Soniya

Consultant Neurologist, Kauvery Hospital, Bengaluru

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