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Meta-Analysis
. 2024 Sep;34(3):713-718.
doi: 10.1007/s00062-024-01414-2. Epub 2024 Apr 30.

Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: a Meta-analysis of Randomized Controlled Trials

Laurens Winkelmeier  1 , Máté Maros  2   3 , Fabian Flottmann  2 , Christian Heitkamp  2 , Gerhard Schön  4 , Götz Thomalla  5 , Jens Fiehler  2 , Uta Hanning  2
Affiliations
Meta-Analysis

Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: a Meta-analysis of Randomized Controlled Trials

Laurens Winkelmeier et al. Clin Neuroradiol. 2024 Sep.

Abstract

Purpose: Randomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0-2 remain scarce.

Methods: We conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0-2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method.

Results: Literature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0-2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29-2.04, P < 0.001).

Conclusion: This meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0-2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0-2.

Keywords: Cerebral infarction; Infarction; Ischemic stroke; Stroke; Thrombectomy.

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Conflict of interest statement

L. Winkelmeier, C. Heitkamp, G. Schön declare that they have no competing interests. M. Maros, F. Flottmann: Personal fees from Eppdata. G. Thomalla: Personal fees from Acandis, Alexion, Amarin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker. J. Fiehler: Personal fees from Acandis, Cerenovus, Medtronic, MicroVention, Medtronic, Penumbra, Phenox, Stryker, Tonbride, and Roche; stocks or stock options from Tegus Medical, Eppdata, and Vastrax. U. Hanning: Personal fees from Eppdata and Stryker.

Figures

Fig. 1
Fig. 1
Flow diagram
Fig. 2
Fig. 2
Random-effects meta-analysis to investigate the 90-day mRS shift in patients with ASPECTS of 0–2 who received endovascular thrombectomy compared with medical management alone. a Forest plot displaying the meta-analysis of four RCTs. The pooled results suggested a significant treatment effect of EVT for patients with ASPECTS of 0–2 (pooled odds ratio, 1.62, 95% CI, 1.29–2.04, P < 0.001). b Same as (a) after exclusion of LASTE. The pooled analysis of trials using CT as primary imaging modality also favored EVT (pooled odds ratio, 1.47, 95% CI, 1.05–2.05, P = 0.02)
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