Eyad Almallouhi, Medical University of South Carolina
Sami Al Kasab, Medical University of South Carolina
Zachary Hubbard, Medical University of South Carolina
Eric C Bass, Medical University of South Carolina
Guilherme Porto, Medical University of South Carolina
Ali Alawieh, Emory University School of Medicine
Reda Chalhoub, Medical University of South Carolina
Pascal Jabbour, Thomas Jefferson UniversityFollow
Robert M Starke, University of Miami Health System
Stacey Q Wolfe, Wake Forest School of Medicine
Adam S Arthur, University of Tennessee Health Science Center
Edgar Samaniego, University of Iowa Hospitals and Clinics
Ilko Maier, University Medical Center Göttingen
Brian M Howard, Emory University School of Medicine
Ansaar Rai, West Virginia School of Medicine
Min S Park, University of Virginia
Justin Mascitelli, University of Texas Health Science Center at San Antonio
Marios Psychogios, University of Basel
Reade De Leacy, Mount Sinai Health System
Travis Dumont, University of Arizona
Michael R Levitt, University of Washington
Adam Polifka, University of Florida
Joshua Osbun, Washington University
Roberto Crosa, Endovascular Neurological Center
Joon-Tae Kim, Chonnam National University Medical School
Walter Casagrande, Hospital Juan Fernandez
Shinichi Yoshimura, Hyogo College of Medicine
Charles Matouk, Yale School of Medicine
Peter T Kan, University of Texas Medical Branch
Richard W Williamson, Allegheny Health Network
Benjamin Gory, Centre Hospitalier Régional Universitaire de Nanc
Maxim Mokin, University of South Florida
Isabel Fragata, Hospital São José Centro Hospitalar
Osama Zaidat, Bon Secours Mercy Health St Vincent Medical Center
Albert J Yoo, Texas Stroke Institute
Alejandro M Spiotta, Medical University of South Carolina

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Publication Date



This article is the author’s final published version in JAMA Network Open, Volume 4, Issue 12, December 2021, Article number e2137708.

The published version is available at Copyright © American Medical Association.


Importance: Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct.

Objective: To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5.

Design, setting, and participants: This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score.

Exposure: All patients underwent MT in one of the included centers.

Main outcomes and measures: A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset).

Results: A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64).

Conclusions and relevance: In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window.

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Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

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