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Randomized Controlled Trial
. 2025 May;56(5):1116-1127.
doi: 10.1161/STROKEAHA.124.050052. Epub 2025 Mar 25.

Thrombectomy With Low ASPECTS: The Roles of Infarct Volume and Postacute Neurological Status

Helge C Kniep #  1 , Susanne Gellißen #  1 , Götz Thomalla  2 , Martin Bendszus  3 , Laurens Winkelmeier  1 , Gabriel Broocks  1   4 , Matthias Bechstein  1 , Fabien Subtil  5   6 , Susanne Bonekamp  3 , Anne Hege Aamodt  7   8 , Blanca Fuentes  9 , Elke R Gizewski  10 , Michael D Hill  11 , Antonin Krajina  12 , Laurent Pierot  13 , Claus Z Simonsen  14 , Kamil Zeleňák  15 , Rolf A Blauenfeldt  14 , Bastian Cheng  2 , Angélique Denis  5   6 , Hannes Deutschmann  16 , Franziska Dorn  17 , Fabian Flottmann  1 , Johannes C Gerber  18   19 , Mayank Goyal  11 , Jozef Haring  20 , Christian Herweh  3 , Silke Hopf-Jensen  21 , Vi Tuan Hua  22 , Märit Jensen  2 , Andreas Kastrup  23 , Christiane Fee Keil  24 , Andrej Klepanec  25 , Egon Kurča  26 , Ronni Mikkelsen  27 , Markus Möhlenbruch  3 , Stefan Müller-Hülsbeck  21 , Nico Münnich  28 , Paolo Pagano  13 , Panagiotis Papanagiotou  29   30 , Gabor C Petzold  31   32 , Mirko Pham  33 , Volker Puetz  19   34 , Jan Raupach  12 , Gernot Reimann  28 , Peter Arthur Ringleb  35 , Maximilian Schell  2 , Eckhard Schlemm  2 , Silvia Schönenberger  35 , Bjørn Tennøe  36 , Christian Ulfert  3 , Kateřina Vališ  37 , Eva Vítková  38 , Dominik F Vollherbst  3 , Wolfgang Wick  35 , Jens Fiehler  1   39 , Lukas Meyer  1 ; TENSION Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Thrombectomy With Low ASPECTS: The Roles of Infarct Volume and Postacute Neurological Status

Helge C Kniep et al. Stroke. 2025 May.

Abstract

Background: Recent randomized trials demonstrated the beneficial effect of endovascular therapy in patients with low Alberta Stroke Program Early CT Score. Despite large follow-up infarct volumes, a significantly increased rate of good functional outcomes was observed, challenging the role of infarct volume as a predictive imaging marker. This analysis evaluates the extent to which the effects of endovascular thrombectomy on functional outcomes are explained by (1) follow-up infarct volume and (2) early neurological status in patients with stroke with low Alberta Stroke Program Early CT Score.

Methods: TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a randomized trial conducted from February 2018 to January 2023 across 41 stroke centers. Two hundred fifty-three patients with ischemic stroke due to anterior circulation large vessel occlusion and Alberta Stroke Program Early CT Score of 3 to 5 were randomized to endovascular thrombectomy plus medical treatment or medical treatment alone. All patients with the availability of relevant data points were included in this secondary as-treated analysis. The primary outcome was the 90-day modified Rankin Scale score. Confounder-adjusted mediation analysis was performed to quantify the proportion of the treatment effect on a 90-day modified Rankin Scale score explained by (1) 24-hour follow-up infarct volume and (2) 24-hour National Institutes of Health Stroke Scale scores.

Results: One hundred eighty-eight patients were included; thereof, 87 (46%) were female patients. Median age was 72 (interquartile range, 63-79) years. The endovascular thrombectomy cohort had a 20.5 (95% CI, 8.3-33.7) percentage points higher probability of achieving independent ambulation (modified Rankin Scale, 0-3) and a 24.2 (95% CI, 13.4-35.8) percentage points lower mortality at 90 days compared with medical treatment alone. The reduction in 24-hour follow-up infarct volume explained 30% of the treatment effect on functional outcomes, while the 24-hour National Institutes of Health Stroke Scale score explained 61%.

Conclusions: In patients with low Alberta Stroke Program Early CT Score, infarct volume demonstrated limited explanatory power for functional outcomes compared with the early neurological status, which may more effectively reflect factors such as the involvement of specific brain regions, disruption of structural networks, and selective neuronal loss.

Keywords: brain; infarction; ischemia; stroke; thrombectomy.

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Conflict of interest statement

Dr Kniep reports compensation as a speaker from Asklepios Kliniken, an ownership stake in eppdata GmbH, and compensation from eppdata GmbH for consultant services. Dr Thomalla reports funding from the European Commission (EUHorizon 2020 Research and Innovation Programme, grant 754640; payments to the institution); personal consulting fees from Acandis, AstraZeneca, Bayer, Boehringer Ingelheim, and Stryker; personal payment or honoraria for lectures, presentations, speakers bureaus, article writing, or educational events from Acandis, Alexion, Marin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, and Stryker; participation as a DSMB member for the TEA Stroke Trial (no payments) and ReSCInD trial (no payments); worked as a speaker of the Commission for Cerebrovascular Diseases of the German Society of Neurology (no payments); and membership of the Board of Directors of the European Stroke Organisation (no payments). Dr Bendszus reports funding from EU Horizon 2020 and Deutsche Forschungsgemeinschaft (payments to the institution); honoraria for lectures from Novartis, Boehringer Ingelheim, and Seagen; and consulting fees from NeuroScios and Boehringer Ingelheim and is an editor-in-chief of Clinical Neuroradiology (Springer). S. Bonekamp reports funding from the EU Horizon 2020 Research and Innovation Programme (grant 754640; payments made to the institution) and EU HORIZON Research and Innovation Action 2021 (project 101057263; payments made to the institution). Dr Broocks reports grants from the American Society of Neuroradiology and compensation from eppdata GmbH for consultant services. Dr Gizewski reports compensation from Medtronic for other services. Dr Kastrup reports compensation from Biogen Idec for consultant services and compensation from Bayer Healthcare for consultant services. Dr Aamodt reports unrestricted research grants from Boehringer Ingelheim; honoraria for lectures from BMS/Pfizer, Teva, Roche, AbbVie, Lundbeck, and Novartis; and participation in advisory boards for MSD, BMS/Pfizer, Lundbeck, Lilly, and AbbVie. Dr Fuentes reports research grants from Carlos III Institute of Health; personal payment for educational lectures from the Servicio Madrileño de Salud; payment for lectures from Euromedice to the institution; personal payment for educational lectures from Takeda; support for attending meetings from Daiichi Sankyo; and receipt of materials for research from Abbot. Dr Hill reports funding from Nil; grants to the University of Calgary for the TEMPO-2 trial from Boehringer Ingelheim, Biogen, NoNO (ESCAPE-NA1 trial and ESCAPE-NEXT trial), Canadian Institutes of Health Research (ESCAPE-NA1 trial and ESCAPE-NEXT trial), Medtronic (HERMES collaboration), and Alberta Innovates (QuICR Alberta Stroke Program); some of the funds were used for the ESCAPE-NA1 trial from Alberta Innovates; consulting fees from Sun Pharma BrainsGate (paid work for adjudication of clinical trial outcomes); US patents 62/086,077 (licensed to Circle NVI) and 10,916,346 (licensed to Circle NVI); private stock ownership from Circle and PUreWeb; participation as data and safety monitoring committee chair of the RACECAT trial (end 2020), the Oncovir Hiltonel trial (ongoing), and the DUMAS trial (ongoing); participation as a data and safety monitoring committee member of the ARTESIA trial (ongoing) and the BRAIN-AF trial (ongoing); and is president of the Canadian Neurological Sciences Federation (not for profit) and a board member of the Canadian Stroke Consortium (not for profit). Dr Krajina reports grants from the European Commission for the TENSION study (payment to the institution). Dr Pierot reports consulting fees from Balt, MicroVention, and Phenox and support for attending meetings or travel for the TENSION investigator meeting (transport and accommodation were reimbursed by the organization). Dr Simonsen reports grants from the Novo Nordisk Foundation and the Health Research Foundation of Central Denmark Region. Dr Blauenfeldt reports speaker fees from Novo Nordisk, Pfizer, and Beyer. Dr Deutschmann reports financial compensation for the start-up fee and the obligatory payment to the hospital administration paid by the sponsor (Medical University Heidelberg) to the clinical division (no personal payments); personal consulting fees from Stryker; speakers honorary from Medtronic; support for attending meetings or travel from Medtronic; and past presidency of the Austrian Society of Interventional Radiology and the Austrian Society of Neuroradiology. Dr Dorn reports consulting fees from MicroVention and Balt; payment for expert testimony from Cerenovus and MicroVention; payment or honoraria for lectures, presentations, speakers bureaus, article writing, or educational events from Cerenovus, Stryker, Acandis, Asahi, Medtronic, Q’Apel, Tonbridge, MicroVention, Inspire, and Penumbra; participation in a data safety monitoring board or an advisory board at Cerenovus and MicroVention; worked as an associate editor for Clinical Neuroradiology and Journal of Clinical Medicine and previously for Journal of NeuroInterventional Surgery. Dr Herweh reports compensation from Brainomix for consultant services. Dr Hopf-Jensen reports compensation from Terumo for consultant services. Dr Goyal reports research grants from Medtronic and Cerenovus (payments to the University of Calgary); royalties or licenses from MicroVention (systems of intracranial access); personal consulting fees from MicroVention, Medtronic, Stryker, Mentice, Philips, and Penumbra; and stock or stock options from Circle Neurovascular. Dr Keil was the chair of the German stroke registry (unpaid). Dr Mikkelsen reports payments for a stroke lecture from TMC Academy. Dr Möhlenbruch reports grants from Balt, Medtronic, MicroVention, and Stryker; consulting fees from Siemens; and support for attending meetings or travel from Europa Group. Dr Müller-Hülsbeck reports consulting fees from Terumo and Boston Scientific Corporation and payment or honoraria for lectures, presentations, speakers’ bureaus, article writing, or educational events from Terumo and Boston Scientific Corporation. Dr Münnich reports the provision of study materials. Dr Pagano reports support for attending meetings or travel for the TENSION investigator meeting (transport and accommodation were reimbursed by the organization). M Pham reports grants from the German Research Foundation (DFG SFB 1158 A10, DFG KFO 5001 P02, DFG KFO 5001 Z, and DFG SFB TR 240 B02); speaker honoraria unrelated from Merck Serono and Bayer; and support for attending meetings or travel from Merck Serono (travel reimbursement) and Bayer (travel reimbursement). Dr Puetz reports lecturer’s fees from Boehringer Ingelheim, Daiichi Sankyo, AstraZeneca, and BMS and travel support from NoNo, Inc. Dr Ringleb reports consulting fees to the institution from Boehringer Ingelheim and Bayer and payment or honoraria for lectures, presentations, speakers’ bureaus, article writing, or educational events from Boehringer Ingelheim, Bayer, Pfizer, and BMS (all made to the institution). Dr Schlemm reports grants from Hamburg Innovation and Hertie Foundation. Dr Vollherbst reports research grants from MicroVention; consulting fees from Medtronic; and paid lectures from Cerenovus and Johnson & Johnson. Dr Wick reports consulting fees to the institution from AbbVie, BMS, GSK, and Servier. Dr Fiehler reports funding from the European Commission; personal consulting fees from Acandis, Cerenovus, Medtronic, MicroVention, Phenox, Stryker, and Roche; consulting at Philips (no payments); payment or honoraria for lectures, presentations, speakers bureaus, article writing, or educational events from Penumbra and Tonbridge; support for attending meetings or travel from Medtronic and Penumbra; stock or stock options from Tegus Medical, eppdata, and Vastrax; and participation in a data safety monitoring board or an advisory board at Phenox (personal fees) and Stryker (personal fees) and is a past president of the European Society of Minimally Invasive Neurological Therapy. Dr Flottmann reports consulting fees from eppdata and support for attending meetings or travels from MicroVention, Medtronic, Cerebrovascular Research and Education Foundation, and Acandis. The other authors report no conflicts.

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