Association Between Alberta Stroke Program Early Computed Tomography Score and Efficacy and Safety Outcomes With Endovascular Therapy in Patients With Stroke From Large-Vessel Occlusion
Authors: Uchida Kazutaka , Shindo Seigo , Yoshimura Shinichi , Toyoda Kazunori , Sakai Nobuyuki , Yamagami Hiroshi , Matsumaru Yuji , Matsumoto Yasushi , Kimura Kazumi , Ishikura Reiichi , Yoshida Astushi , Inoue Manabu , Beppu Mikiya , Sakakibara Fumihiro , Shirakawa Manabu , Morimoto Takeshi ,   RESCUE-Japan LIMIT Investigators, Kuwayama Naoya , Ogasawara Kuniaki , Hirano Teruyuki , Kinjo Norito , Saito Takuya , Takeuchi Masataka , Yazawa Yukako , Kimura Naoto , Shigeta Keigo , Imamura Hirotoshi , Suzuki Ichiro , Enomoto Yukiko , Tokunaga So , Morita Kenichi , Tanaka Kanta , Kanazawa Ryuzaburo , Asai Takumi , Shimamura Norihito , Ishihara Hideyuki , Morimoto Masafumi , Ohnishi Hiroyuki , Akiyama Yoshinori , Matsushita Nobuhisa , Yamamoto Nobuaki , Haraguchi Koichi , Araki Hayato , Ogata Atsushi , Okumura Hirotaka , Ogino Tatsuya , Yamada Yoshitaka , Ota Takahiro , Tsuboi Yoshifumi , Yamada Takehiro , Nagata Manabu , Todo Kenichi , Shimizu Fuminori , Ueno Yasushi , Yoshimura Masataka , Tsuruta Wataro , Morofuji Yoichi , Toma Naoki , Omae Tomoya , Sakamoto Makoto , Ueda Toshihiro , Koyama Shinya 
Published: October 2022

Importance

Endovascular therapy (EVT) has been found to reduce functional disability in patients with acute stroke due to large-vessel occlusion. However, the extent of the ischemic region, measured using Alberta Stroke Program Early Computed Tomography Scores, may limit the efficacy of EVT.

Objective

To compare the efficacy and safety of EVT according to ASPECTS 3 or less vs 4 to 5.

Design, Setting, and Participants

The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism—Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT) was an open-label randomized clinical trial conducted from November 2018 to December 2021 at 45 stroke centers across Japan. The trial enrolled adult patients with acute ischemic stroke with a large ischemic region, defined as ASPECTS 3 to 5 primarily determined by magnetic resonance imaging, with occlusion site at the internal carotid artery or middle cerebral artery segment 1. Among 203 enrolled patients, 1 withdrew consent and 202 were included in the original trial and secondary analysis. This secondary analysis was conducted in April 2022.

Interventions

Patients were randomly assigned to EVT with medical therapy or medical therapy alone.

Main Outcomes and Measures

Modified Rankin Scale (mRS) score at 90 days and symptomatic and any intracranial hemorrhage within 48 hours.

Results

Among 202 patients, 106 (52%) had ASPECTS 3 or less (mean [SD] age, 76.7 [9.6] years; 54 female individuals [50.9%]) and 96 had ASPECTS 4 to 5 (mean [SD] age, 75.6 [10.6] years; 36 female individuals [37.5%]). Of patients with ASPECTS 3 or less, 12 (21.4%) in the EVT group and 9 (18.0%) in the no EVT group had an mRS score of 0 to 3 (odds ratio [OR], 1.24; 95% CI, 0.47-3.26). Of patients with ASPECTS 4 to 5, 19 patients (43.2%) in the EVT group and 4 (7.7%) in the no EVT group had an mRS score of 0 to 3 at 90 days (OR, 9.12; 95% CI, 2.80-29.70; interaction P = .01). The ordinal shift across the range of mRS scores toward a better outcome was not significant in those with ASPECTS or 3 or less (common OR, 1.56; 95% CI, 0.79-3.10) but was significant in those with ASPECTS 4 to 5 (common OR, 4.48; 95% CI, 2.07-9.71; interaction P = .046). The risk of intracranial hemorrhage was significantly increased in patients with ASPECTS 3 or less when EVT was conducted (OR, 4.14; 95% CI, 1.84-9.32) and nonsignificantly increased in those with ASPECTS 4 to 5 (OR, 2.05; 95% CI, 0.89-4.73; interaction P = .24).

Conclusions and Relevance

In this study, EVT was associated with improved 90-day functional outcomes in patients with acute large vessel occlusive stroke and ASPECTS was 4 to 5 but not in those with ASPECTS 3 or less.

Trial Registration

ClinicalTrials.gov Identifier: NCT03702413