Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct
Dapeng Sun, Xu Guo, Thanh N. Nguyen, Yuesong Pan, Gaoting Ma, Xu Tong, Raynald, Mengxing Wang, Ning Ma, Feng Gao, Dapeng Mo, Xiaochuan Huo, Zhongrong Miao, ANGEL-ASPECT Study Group, Guangxiong Yuan, Hongxing Han, Wenhuo Chen, Ming Wei, Jiangang Zhang, Zhimin Zhou, Xiaoxi Yao, Guoqing Wang, Weigen Song, Xueli Cai, Guangxian Nan, Di Li, Alvin Yi-Chou Wang, Wentong Ling, Chuwei Cai, Changming Wen, En Wang, Liyong Zhang, Changchun Jiang, Yajie Liu, Geng Liao, Xiaohui Chen, Tianxiao Li, Shudong Liu, Jinglun Li, Yaxuan Sun, Na Xu, Zongen Gao, Dongsheng Ju, Cunfeng Song, Jinggang Xuan, Feng Zhou, Qing Shi, Jun Luo, Yan Liu, Zaiyu Guo, Tong Li, Hongbo Zheng, Linzhi Dai, Junfeng Zhao, Liqiang Gui, Xiaokun Geng, Yufeng Tang, Congguo Yin, Hua Yang, Yongjun Wang, Yilong Wang, Liping Liu, David S. Liebeskind, Zeguang Ren, Vítor Mendes Pereira, Xunming Ji, Qiang Dong, Anding Xu, Xinfeng Liu, Qingwu Yang, Jing Jing, Zhe Zhang, Yingkui Zhang, Wei Wu, Zhongqi Qi, Shuo Li, Zequan Yu, Jingyu Zhang, Fangguang Chen, Kangyue Li, Kai Zhang, Mingkai Hu, Jianmin Liu, Yao Chen, Kangning Chen, Kun Fang, Bo Song, Yi Dong, Ruiyang An, Yuying Sun, Yanan Wu, Chunlai Yu, Shuangcheng Zheng, Aoming Jin, Xianglong Xiang, Hongyi Yan, Yuanling He, Chunyang Li, Wei-Xia Kong, Yuhuan Chen
Abstract
Importance: Endovascular therapy (EVT) demonstrated better outcomes compared with medical management in recent randomized clinical trials (RCTs) of patients with large infarct. Objective: To compare outcomes of EVT vs medical management across different strata of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and infarct core volume in patients with large infarct. Design, Setting, and Participants: This prespecified secondary analysis of subgroups of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) RCT included patients from 46 stroke centers across China between October 2, 2020, and May 18, 2022. Participants were enrolled within 24 hours of symptom onset and had ASPECTS of 3 to 5 or 0 to 2 and infarct core volume of 70 to 100 mL. Patients were divided into 3 groups: ASPECTS of 3 to 5 with infarct core volume less than 70 mL, ASPECTS of 3 to 5 with infarct core volume of 70 mL or greater, and ASPECTS of 0 to 2. Interventions: Endovascular therapy or medical management. Main Outcomes and Measures: The primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score. Results: There were 455 patients in the trial; median age was 68 years (IQR, 60-73 years), and 279 (61.3%) were male. The treatment effect did not vary significantly across the 3 baseline imaging subgroups (P = .95 for interaction). The generalized odds ratio for the shift in the 90-day mRS distribution toward better outcomes with EVT vs medical management was 1.40 (95% CI, 1.06-1.85; P = .01) in patients with ASPECTS of 3 to 5 and infarct core volume less than 70 mL, 1.22 (95% CI, 0.81-1.83; P = .23) in patients with ASPECTS of 3 to 5 and infarct core volume of 70 mL or greater, and 1.59 (95% CI, 0.89-2.86; P = .09) in patients with ASPECTS of 0 to 2. Conclusions and Relevance: In this study, no significant interaction was found between baseline imaging status and the benefit of EVT compared with medical management in patients with large infarct core volume. However, estimates within subgroups were underpowered. A pooled analysis of large core trials stratified by ASPECTS and infarct core volume strata is warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT04551664.