Is there a benefit of mechanical thrombectomy in patients with large stroke (DWI‐ASPECTS ≤ 5)?

• Published in: European journal of neurology Vol. 25; no. 1; pp. 105 - 110
• Main Authors: Manceau, P. ‐F., Soize, S., Gawlitza, M., Fabre, G., Bakchine, S., Durot, C., Serre, I., Metaxas, G. ‐E., Pierot, L.
• Format: Journal Article
• Language: English
• Published: England John Wiley & Sons, Inc 01-01-2018
• Subjects: Blood glucose; Cerebral infarction; Computed tomography; Confidence intervals; diffusion‐weighted imaging; Genetic transformation; Hematoma; Hemorrhage; Infarction; Intravenous administration; Lesions; magnetic resonance imaging; Markers; Patients; State of the art; Statistical analysis; Stroke; thrombectomy; Thrombolysis; magnetic resonance imaging; diffusion-weighted imaging; stroke; thrombectomy
• ISSN: 1351-5101; 1468-1331
• DOI: 10.1111/ene.13460

Background and purpose
Whether to withhold mechanical thrombectomy when the diffusion‐weighted imaging (DWI) lesion exceeds a given volume is undetermined. Our aim was to identify markers that will help to select patients with large DWI lesions [DWI−Alberta Stroke Program Early Computed Tomography Score (DWI‐ASPECTS) ≤ 5] that may benefit from thrombectomy.
Methods
From May 2010 to November 2016, 82 acute ischaemic stroke patients with DWI‐ASPECTS ≤5 (43 men, 64.6 ± 14.4 years, National Institutes of Health Stroke Scale 18.4 ± 5.4) treated with state‐of‐the‐art mechanical thrombectomy were studied. Thrombectomy alone was performed in 28 (34%) and bridging therapy in 54 (66%) patients. Recanalization was defined as a thrombolysis in cerebral infarction score 2B‐3 and significant hemorrhagic transformation as parenchymal haematoma type 2 (European Cooperative Acute Stroke Study 3 classification). Pretreatment variables were compared between patients with a good (modified Rankin Scale 0−2) and a poor (modified Rankin Scale 3−6) neurological outcome at 3 months.
Results
Overall, 28 patients (34%) achieved good neurological outcome at 3 months. Recanalizers were significantly more likely to achieve good outcome (61% vs. 7.3%, P < 0.0001), had lower mortality (24% vs. 49%, P = 0.03) and similar rates of parenchymal haematoma type 2 (9.8% vs. 7.3%, P = 1) compared to non‐recanalizers. Regression modelling identified DWI‐ASPECTS >2 [odds ratio (OR) 6.93; 95% confidence interval (CI) 1.05–45.76, P = 0.04), glycaemia ≤6.8 mmol/l (OR 4.05; 95% CI 1.09–15.0, P = 0.03) and thrombolysis (OR 3.67; 95% CI 1.04–12.9, P = 0.04) as independent predictors of good neurological outcome.
Conclusions
In patients with DWI‐ASPECTS ≤5, two‐thirds of patients experienced good neurological outcome when recanalized by state‐of‐the‐art thrombectomy, whilst only one in 14 non‐recanalizers achieved similar outcomes. Pretreatment markers of good neurological outcomes were DWI‐ASPECTS >2, intravenous thrombolysis and glycaemia ≤6.8 mmol/l.