Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Apostolos Safouris; Lina Palaiodimou; István Szikora; Odysseas Kargiotis; George Magoufis; Klearchos Psychogios; Georgios Paraskevas; Stavros Spiliopoulos; Elias Brountzos; Sándor Nardai; Nitin Goyal; Diana Aguiar De Sousa; Daniel Strbian; Valeria Caso; Andrei Alexandrov; Georgios Tsivgoulis

doi:10.1177/17562864221139632

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

Ther Adv Neurol Disord. 2022 Nov 29:15:17562864221139632. doi: 10.1177/17562864221139632. eCollection 2022.

Authors

Apostolos Safouris^{1

2

3

4

5}, Lina Palaiodimou^{2

3}, István Szikora⁵, Odysseas Kargiotis¹, George Magoufis⁶, Klearchos Psychogios¹, Georgios Paraskevas^{2

3}, Stavros Spiliopoulos⁷, Elias Brountzos⁷, Sándor Nardai⁵, Nitin Goyal^{8

9}, Diana Aguiar De Sousa¹⁰, Daniel Strbian¹¹, Valeria Caso¹², Andrei Alexandrov⁸, Georgios Tsivgoulis^{13

3

8}

Affiliations

¹ Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
² Second Department of Neurology, Attikon University Hospital, Athens, Greece.
³ School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
⁴ Aktios Rehabilitation Center, Athens, Greece.
⁵ Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Section of Neurointervention, Department of Neurosurgery, Semmelweis University, Budapest, Hungary.
⁶ Neuroradiology Department, Metropolitan Hospital, Piraeus, Greece.
⁷ Interventional Radiology Department, Attikon University Hospital, Athens, Greece.
⁸ Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA.
⁹ Department of Neurosurgery, The University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
¹⁰ Stroke Center, Lisbon Central University Hospital and Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
¹¹ Neurological Research Unit, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹² Neurology Unit, 'M. Bufalini' Hospital-AUSL Romagna, Cesena, Italy.
¹³ Second Department of Neurology, Attikon University Hospital, Rimini 1, Chaidari, 124 62 Athens, Greece.

Abstract

Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials.

Objectives: The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial.

Design: Systematic review and meta-analysis of available studies in accordance with the PRISMA statement.

Data sources and methods: We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months.

Results: Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71).

Conclusion: EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients.

Registration: The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.

Keywords: ASPECTS; endovascular treatment; large-vessel occlusion; modified Rankin scale; mortality; stroke; symptomatic intracranial hemorrhage.