Thrombectomy Benefits Large-Core Stroke Patients After Transfer
- Patients with acute ischemic stroke and large vessel occlusion (AIS-LVO) who have large or very large ischemic cores benefit from mechanical thrombectomy compared to medical management alone, according...
- Researchers evaluated 157 patients with anterior circulation AIS-LVO who had large ischemic cores, defined by an Alberta Stroke Program Early CT Score (ASPECTS) of 0-5.
- Specifically, 31.6% of patients in the thrombectomy group achieved mRS scores of 0-3 at 90 days, compared to 11.4% in the control group.
Patients with acute ischemic stroke and large vessel occlusion (AIS-LVO) who have large or very large ischemic cores benefit from mechanical thrombectomy compared to medical management alone, according to a post hoc analysis of the LASTE randomized controlled trial published September 22 in the Annals of Neurology. The findings indicate that patients identified at primary stroke centers (PSCs) prior to interhospital transfer experience better functional outcomes when undergoing the procedure.
Functional Outcomes and Neurologic Improvement
Researchers evaluated 157 patients with anterior circulation AIS-LVO who had large ischemic cores, defined by an Alberta Stroke Program Early CT Score (ASPECTS) of 0-5. Patients were randomized to receive either thrombectomy plus medical management (n=77) or medical management alone (n=80) within 6.5 hours of last seen well at the comprehensive stroke center. At 90 days post-randomization, the thrombectomy group showed a shift toward lower scores on the modified Rankin Scale (mRS), which measures disability, compared to those receiving only medical management (generalized odds ratio [GenOR], 1.71; P = .002). This benefit remained sustained at 180 days (GenOR, 1.66; 95% CI, 1.17-2.35).
Secondary outcomes also favored the intervention group. Specifically, 31.6% of patients in the thrombectomy group achieved mRS scores of 0-3 at 90 days, compared to 11.4% in the control group. Early neurologic improvement—defined as a reduction of ≥ 8 points in the National Institutes of Health Stroke Scale score—was observed in 24.7% of the thrombectomy group, versus 5.2% in the medical management group (relative risk [RR], 4.75; 95% CI, 1.68-13.37). The intervention group also saw smaller infarct growth at 24 hours, with an adjusted mean difference of -64 mL (95% CI, -88 to -40).
Efficacy in Very Large Core Patients
The study found that the benefits of thrombectomy persisted even among patients with very large cores, categorized as ASPECTS 0-2 (GenOR, 1.87; 95% CI, 1.18-2.94). The positive results also held for patients who did not undergo repeat imaging upon arrival at the comprehensive stroke center (CSC) (GenOR, 1.93; 95% CI, 1.27-2.92). While the study noted that the benefit of achieving independent ambulation (mRS 0-3) decreased as transfer time increased, medical management outcomes remained unaffected by the duration of the transfer.
Safety Considerations and Study Limitations
Safety data showed that symptomatic intracerebral hemorrhage within 24 hours occurred more frequently in the thrombectomy group, though this difference was not statistically significant. Similarly, while 90-day mortality was lower in the intervention group, the difference did not reach statistical significance. The study, led by Pierre Seners, MD, PhD, of the Hôpital Fondation A. de Rothschild in Paris, France, acknowledged limitations including a moderate sample size and the absence of assessment regarding the extent of selection bias.
Clinical Implications for Interhospital Transfer
The investigators suggest these results support the proactive transfer of patients with large ischemic cores from primary stroke centers to comprehensive centers for thrombectomy. The authors stated:
“These findings support consideration of interhospital transfer for thrombectomy in AIS-LVO patients with large ischemic cores, including ASPECTS of 0 to 2, admitted in PSC in the early time-window, and direct-to-angiosuite protocol on admission at the comprehensive stroke center.”
Pierre Seners, MD, PhD, et al.
The LASTE trial received funding from Montpellier University Hospital via an unrestricted grant from a consortium of medical device manufacturers, including Balt Extrusion, Cerenovus, Medtronic, MicroVention, and Stryker. The authors reported no relevant conflicts of interest.