Huanwen Chen, Jin Soo Lee, Patrik Michel, Bernard Yan, Seemant Chaturvedi
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Overall, the results appeared to be positive, with 5 of the 6 trials meeting their primary efficacy end point, and 1 trial that was a near miss. However, questions remain regarding how these trial results should be interpreted and incorporated into routine clinical practice.</p><p><strong>Observations: </strong>In this narrative review and analysis of published trials, important nuances of the available clinical data were identified, and important areas of lingering uncertainty were highlighted, including the efficacy and safety of EVT for patients with a low ASPECTS score in late treatment windows and those with large core volumes. Also emphasized was the possibly important role of advanced neuroimaging modalities such as perfusion and magnetic resonance imaging when making EVT treatment decisions for select patients with low ASPECTS scores.</p><p><strong>Conclusions and relevance: </strong>Recent trial data provide strong evidence that EVT is safe and effective for patients with anterior, large vessel-occlusion stroke and low ASPECTS scores who present within 6 hours from stroke onset. However, patient outcomes often remain poor despite EVT treatment. The efficacy and safety of EVT for patients with low ASPECTS scores who present beyond 6 hours of stroke onset remain uncertain, and the current trial data seem too scarce to justify forgoing advanced stroke imaging during this extended time window. Furthermore, the efficacy and safety of EVT for patients with large core volumes (100 mL or greater) or M2 occlusions (ie, occlusions of the second segment of the middle cerebral artery) remain uncertain. Future research to better identify patients likely to meaningfully respond to EVT is needed to further optimize the stroke triage process and health care resource utilization.</p>","PeriodicalId":14677,"journal":{"name":"JAMA neurology","volume":" ","pages":"1085-1093"},"PeriodicalIF":20.4000,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Endovascular Stroke Thrombectomy for Patients With Large Ischemic Core: A Review.\",\"authors\":\"Huanwen Chen, Jin Soo Lee, Patrik Michel, Bernard Yan, Seemant Chaturvedi\",\"doi\":\"10.1001/jamaneurol.2024.2500\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Importance: </strong>Recently, 6 randomized clinical trials-RESCUE-Japan-LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial), ANGEL-ASPECT (Trial of Endovascular Therapy for Acute Ischemic Stroke With Large Infarct), SELECT2 (Trial of Endovascular Thrombectomy for Large Ischemic Strokes), TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke), TENSION (Endovascular Thrombectomy for Acute Ischemic Stroke With Established Large Infarct), and LASTE (Large Stroke Therapy Evaluation)-have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for the treatment of patients with ischemic stroke, anterior-circulation large vessel occlusions, and large areas of ischemic changes defined as an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 5 or less. Overall, the results appeared to be positive, with 5 of the 6 trials meeting their primary efficacy end point, and 1 trial that was a near miss. However, questions remain regarding how these trial results should be interpreted and incorporated into routine clinical practice.</p><p><strong>Observations: </strong>In this narrative review and analysis of published trials, important nuances of the available clinical data were identified, and important areas of lingering uncertainty were highlighted, including the efficacy and safety of EVT for patients with a low ASPECTS score in late treatment windows and those with large core volumes. Also emphasized was the possibly important role of advanced neuroimaging modalities such as perfusion and magnetic resonance imaging when making EVT treatment decisions for select patients with low ASPECTS scores.</p><p><strong>Conclusions and relevance: </strong>Recent trial data provide strong evidence that EVT is safe and effective for patients with anterior, large vessel-occlusion stroke and low ASPECTS scores who present within 6 hours from stroke onset. However, patient outcomes often remain poor despite EVT treatment. The efficacy and safety of EVT for patients with low ASPECTS scores who present beyond 6 hours of stroke onset remain uncertain, and the current trial data seem too scarce to justify forgoing advanced stroke imaging during this extended time window. Furthermore, the efficacy and safety of EVT for patients with large core volumes (100 mL or greater) or M2 occlusions (ie, occlusions of the second segment of the middle cerebral artery) remain uncertain. 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引用次数: 0
摘要
重要性:最近,6 项随机临床试验--RESCUE-Japan-LIMIT(Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial)、ANGEL-ASPECT(Trial of Endovascular Therapy for Acute Ischemic Stroke With Large Infarct)、SELECT2(大面积缺血性脑卒中血管内血栓切除术试验)、TESLA(大面积前循环缺血性脑卒中紧急抢救血栓切除术)、TENSION(大面积梗死急性缺血性卒中血管内血栓切除术)和 LASTE(大面积卒中治疗评估)--已经完成了对血管内血栓切除术(EVT)治疗缺血性卒中、前循环大血管闭塞和大面积缺血性病变(定义为阿尔伯塔卒中计划早期计算机断层扫描评分(ASPECTS)5 分或以下)患者的有效性和安全性的研究。总的来说,结果似乎是积极的,6 项试验中有 5 项达到了主要疗效终点,1 项试验几乎没有达到。然而,如何解释这些试验结果并将其纳入常规临床实践仍存在疑问:在对已发表的试验进行的叙述性回顾和分析中,发现了现有临床数据的重要细微差别,并强调了仍存在不确定性的重要领域,包括 EVT 对晚期治疗窗口期 ASPECTS 评分较低的患者和核心体积较大的患者的疗效和安全性。此外,还强调了先进的神经成像模式(如灌注成像和磁共振成像)在选择ASPECTS评分较低的患者进行EVT治疗决策时可能发挥的重要作用:最近的试验数据提供了强有力的证据,证明 EVT 对于卒中发生后 6 小时内出现的前方大血管闭塞性卒中和 ASPECTS 评分低的患者是安全有效的。然而,尽管进行了 EVT 治疗,患者的预后仍然很差。对于卒中发生 6 小时后出现的 ASPECTS 评分较低的患者,EVT 的有效性和安全性仍不确定,目前的试验数据似乎太少,不足以证明在这一延长时间窗内放弃高级卒中成像是合理的。此外,对于核心容量较大(100 mL 或以上)或 M2 闭塞(即大脑中动脉第二段闭塞)的患者,EVT 的有效性和安全性仍不确定。未来的研究需要更好地识别可能对 EVT 有意义反应的患者,以进一步优化卒中分流流程和医疗资源的利用。
Endovascular Stroke Thrombectomy for Patients With Large Ischemic Core: A Review.
Importance: Recently, 6 randomized clinical trials-RESCUE-Japan-LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial), ANGEL-ASPECT (Trial of Endovascular Therapy for Acute Ischemic Stroke With Large Infarct), SELECT2 (Trial of Endovascular Thrombectomy for Large Ischemic Strokes), TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke), TENSION (Endovascular Thrombectomy for Acute Ischemic Stroke With Established Large Infarct), and LASTE (Large Stroke Therapy Evaluation)-have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for the treatment of patients with ischemic stroke, anterior-circulation large vessel occlusions, and large areas of ischemic changes defined as an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 5 or less. Overall, the results appeared to be positive, with 5 of the 6 trials meeting their primary efficacy end point, and 1 trial that was a near miss. However, questions remain regarding how these trial results should be interpreted and incorporated into routine clinical practice.
Observations: In this narrative review and analysis of published trials, important nuances of the available clinical data were identified, and important areas of lingering uncertainty were highlighted, including the efficacy and safety of EVT for patients with a low ASPECTS score in late treatment windows and those with large core volumes. Also emphasized was the possibly important role of advanced neuroimaging modalities such as perfusion and magnetic resonance imaging when making EVT treatment decisions for select patients with low ASPECTS scores.
Conclusions and relevance: Recent trial data provide strong evidence that EVT is safe and effective for patients with anterior, large vessel-occlusion stroke and low ASPECTS scores who present within 6 hours from stroke onset. However, patient outcomes often remain poor despite EVT treatment. The efficacy and safety of EVT for patients with low ASPECTS scores who present beyond 6 hours of stroke onset remain uncertain, and the current trial data seem too scarce to justify forgoing advanced stroke imaging during this extended time window. Furthermore, the efficacy and safety of EVT for patients with large core volumes (100 mL or greater) or M2 occlusions (ie, occlusions of the second segment of the middle cerebral artery) remain uncertain. Future research to better identify patients likely to meaningfully respond to EVT is needed to further optimize the stroke triage process and health care resource utilization.
期刊介绍:
JAMA Neurology is an international peer-reviewed journal for physicians caring for people with neurologic disorders and those interested in the structure and function of the normal and diseased nervous system. The Archives of Neurology & Psychiatry began publication in 1919 and, in 1959, became 2 separate journals: Archives of Neurology and Archives of General Psychiatry. In 2013, their names changed to JAMA Neurology and JAMA Psychiatry, respectively. JAMA Neurology is a member of the JAMA Network, a consortium of peer-reviewed, general medical and specialty publications.