Abstract
The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of endovascular treatment patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late endovascular treatment. We retrospectively analyzed all consecutive acute ischemic stroke patients admitted 6-24 h after last proof of good health in two stroke centers, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS ≥ 10 and ASPECTS ≥ 7, or NIHSS ≥ 20 and ASPECTS ≥ 5. We assessed the interaction between the presence of the clinical-ASPECTS mismatch and late endovascular treatment using ordinal shift analysis of the three-month modified Rankin Scale and adjusting for multiple confounders. The included 337 patients had a median age of 73 years (IQR = 61-82), admission NIHSS of 18 (15-22), and baseline ASPECTS of 7 (5-9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late endovascular treatment. Among 141 (41.8%) mismatch negative patients, late endovascular treatment was performed in 72 (51.1%) patients. In the adjusted analysis, late endovascular treatment was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted odd ratio, aOR = 2.83; 95% confidence interval, CI: 1.48-5.58) but not in its absence (aOR = 1.32; 95%CI: 0.61-2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late endovascular treatment was 0.073. In our retrospective two-site analysis, late endovascular treatment seemed effective in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late endovascular treatment decisions, obviating the need for advanced imaging.
Highlights
The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch
We previously demonstrated that the proportion of lateadmitted acute ischemic stroke (AIS) eligible for endovascular treatment (EVT) according to strict trial criteria was low in the real-life scenario.[4]
218 (9.7%) patients presented with admission National Institutes of Health Stroke Scale (NIHSS) !10 and ICA/M1 occlusion, and were included in the EVTarm
Summary
The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch. The Alberta Stroke Program Early CT Score (ASPECTS) is an applicable tool to estimate the amount of irreversibly damaged brain tissue in the middle cerebral artery (MCA) territory strokes.[6] Originally designed for non-contrast CT scan (NCCT), it has been applied to diffusion-weighted imaging (DWI) sequences, after one-point adjustment.[7] the role of ASPECTS in selecting patients who are most likely to benefit from EVT is not clearly established in the late time window.[8,9] to the best of our knowledge, its use in association of clinical stroke severity as a surrogate of the core-penumbra mismatch[1] has not been evaluated
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