Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct
Authors: Sun Dapeng , Guo Xu , Nguyen Thanh N. , Pan Yuesong , Ma Gaoting , Tong Xu , Raynald  , Wang Mengxing , Ma Ning , Gao Feng , Mo Dapeng , Huo Xiaochuan , Miao Zhongrong ,   ANGEL-ASPECT Study Group, Yuan Guangxiong , Han Hongxing , Chen Wenhuo , Wei Ming , Zhang Jiangang , Zhou Zhimin , Yao Xiaoxi , Wang Guoqing , Song Weigen , Cai Xueli , Nan Guangxian , Li Di , Wang Alvin Yi-Chou , Ling Wentong , Cai Chuwei , Wen Changming , Wang En , Zhang Liyong , Jiang Changchun , Liu Yajie , Liao Geng , Chen Xiaohui , Li Tianxiao , Liu Shudong , Li Jinglun , Sun Yaxuan , Xu Na , Gao Zong'en , Ju Dongsheng , Song Cunfeng , Xuan Jinggang , Zhou Feng , Shi Qing , Luo Jun , Liu Yan , Guo Zaiyu , Li Tong , Zheng Hongbo , Dai Linzhi , Zhao Junfeng , Gui Liqiang , Geng Xiaokun , Tang Yufeng , Yin Congguo , Yang Hua , Wang Yongjun , Wang Yilong , Liu Liping , Liebeskind David , Ren Zeguang , Pereira Vitor , Ji Xunming , Dong Qiang , Xu Anding , Liu Xinfeng , Yang Qingwu , Jing Jing , Zhang Zhe , Zhang Yingkui , Wu Wei , Qi Zhongqi , Li Shuo , Yu Zequan , Zhang Jingyu , Chen Fangguang , Li Kangyue , Zhang Kai , Hu Mingkai , Liu Jianmin , Yao Chen , Chen Kangning , Fang Kun , Song Bo , Dong Yi , An Ruiyang , Sun Yuying , Wu Yanan , Yu Chunlai , Zheng Shuangcheng , Jin Aoming , Xiang Xianglong , Yan Hongyi , He Yuanling , Li Chunyang , Kong Weixia , Chen Yuhuan , Guo Chenhao , Ji Fengjie , Ji Pengshan , Liu Lei , Lu Xinghua , Luo Guangkuo , Wang Nanjing , Zhang Yu , Liu Bo , Yang Jian , Deng Jingjing , Wang Juan , Wang Wanru , Yu Hang , Cui Le , Liu Wenwen , Wang Ziyong , Zhao Xia , Zhou Zhou 
Published: November 2023

Importance

Endovascular therapy (EVT) demonstrated better outcomes compared with medical management in recent randomized clinical trials (RCTs) of patients with large infarct.

Objective

To compare outcomes of EVT vs medical management across different strata of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and infarct core volume in patients with large infarct.

Design, Setting, and Participants

This prespecified secondary analysis of subgroups of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) RCT included patients from 46 stroke centers across China between October 2, 2020, and May 18, 2022. Participants were enrolled within 24 hours of symptom onset and had ASPECTS of 3 to 5 or 0 to 2 and infarct core volume of 70 to 100 mL. Patients were divided into 3 groups: ASPECTS of 3 to 5 with infarct core volume less than 70 mL, ASPECTS of 3 to 5 with infarct core volume of 70 mL or greater, and ASPECTS of 0 to 2.

Interventions

Endovascular therapy or medical management.

Main Outcomes and Measures

The primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score.

Results

There were 455 patients in the trial; median age was 68 years (IQR, 60-73 years), and 279 (61.3%) were male. The treatment effect did not vary significantly across the 3 baseline imaging subgroups (P = .95 for interaction). The generalized odds ratio for the shift in the 90-day mRS distribution toward better outcomes with EVT vs medical management was 1.40 (95% CI, 1.06-1.85; P = .01) in patients with ASPECTS of 3 to 5 and infarct core volume less than 70 mL, 1.22 (95% CI, 0.81-1.83; P = .23) in patients with ASPECTS of 3 to 5 and infarct core volume of 70 mL or greater, and 1.59 (95% CI, 0.89-2.86; P = .09) in patients with ASPECTS of 0 to 2.

Conclusions and Relevance

In this study, no significant interaction was found between baseline imaging status and the benefit of EVT compared with medical management in patients with large infarct core volume. However, estimates within subgroups were underpowered. A pooled analysis of large core trials stratified by ASPECTS and infarct core volume strata is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04551664