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July 29, 2019

SELECTing Patients With Large Ischemic Core Who May Benefit From Endovascular Reperfusion

Author Affiliations
  • 1Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
JAMA Neurol. Published online July 29, 2019. doi:10.1001/jamaneurol.2019.1789

In this issue of JAMA Neurology, Sarraj et al1 report on the clinical and radiologic outcomes in an observational cohort of 105 patients who had extensive ischemic changes on noncontrast computed tomographic (CT) scans (Alberta Stroke Program Early CT Scores [ASPECTS] of 0-5) or CT perfusion scans with ischemic core volume greater than 50 mL and who were treated within 24 hours of stroke onset with endovascular thrombectomy or medical management. All but 1 of the patients who received endovascular treatment and were included based on low ASPECTS had a score of 4 or 5. The ASPECTS regions are not volumetrically or functionally equal, and so the category of those with scores of 0 to 5 encompassed patients with a large range of ischemic core volumes and potential functional outcomes. Only 40 of 71 patients (56%) with ASPECTS of 0 to 5 had core volumes greater than 50 mL on CT perfusion images. Patients who had thrombectomies had improved outcomes in an unadjusted statistical analysis, but these differences did not remain significant after adjustment for baseline age, clinical severity, and other key prognostic variables. However, the analysis was underpowered. A key finding was that favorable outcomes in these patients with large core volumes was strongly time dependent, which was consistent with previous data from the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) collaboration.2