endovascular thrombectomy can be beneficial to acute

CLINICAL ARTICLEJ Neurosurg 130:1383–1390, 2019

Acute ischemic stroke (AIS) is a serious disease with high morbidity and mortality rates. It is gen-erally believed that timely reperfusion in ischemic

stroke patients is an effective therapy to decrease long-term morbidity.25 Intravenous (IV) thrombolysis and endo-vascular thrombectomy are two major priority strategies to achieve vascular recanalization. Therapy with intravenous recombinant tissue-type plasminogen activator (r-tPA) is the mainstay early treatment for patients with AIS eligible

for thrombolysis, which is commonly used in the clinical setting. However, the narrow time window and restrictive selection criteria limited its scope of use.17 Most recently, the endovascular intervention (mechanical thrombectomy) has shown significant advantages over thrombolysis in pa-tients with large vascular occlusions.3,8,23 As a result, either thrombectomy or thrombolysis is considered for reperfu-sion with a low risk as soon as the disease occurs. There-fore, according to the updated guideline, the American

ABBREVIATIONS AHA/ASA = American Heart Association/American Stroke Association; AIS = acute ischemic stroke; ASPECTS = Alberta Stroke Program Early CT Score; CI = confidence interval; IV = intravenous; MCA = middle cerebral artery; MR CLEAN = Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; OR = odds ratio; r-tPA = recombinant tissue-type plasminogen activator; sICH = symptomatic intracranial hemorrhage.SUBMITTED May 26, 2017. ACCEPTED November 4, 2017.INCLUDE WHEN CITING Published online May 11, 2018; DOI: 10.3171/2017.11.JNS171297.* S.J., Y.P., and C.H.J. contributed equally to this work.

Endovascular thrombectomy can be beneficial to acute ischemic stroke patients with large infarcts*Shaowei Jiang, MD,1 Ya Peng, MD, PhD,3 Chao-hui Jing, MD, PhD,2 Ai-hua Fei, MD, PhD,1 Hai-rong Wang, MD, PhD,1 Cheng-jin Gao, MD, PhD,1 Miao Chen, MD, PhD,1 Yi Li, MD, PhD,2 and Shuming Pan, MD, PhD1

1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai; 2Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai; and 3Cerebral Vascular Disease Center, The First People’s Hospital of Changzhou, Soochow University, Changzhou, China

OBJECTIVE This study aimed to assess whether patients with acute ischemic stroke (AIS) and large infarct lesions benefit from reperfusion management. To determine the efficacy of different recanalization managements on AIS pa-tients with Alberta Stroke Program Early CT Score (ASPECTS) < 6, the authors retrospectively analyzed hospitalized patients with AIS.METHODS Eighty-nine patients with AIS and ASPECTS < 6 were screened from 13,285 hospitalized patients treated by thrombolysis, thrombectomy, or conventional care in two stroke medical centers. Logistic regression or Fisher’s exact test was performed for comparison of the outcome and risk events between patients treated by thrombectomy (or throm-bolysis) and conventional care. The modified Rankin Scale (mRS) score was used to assess the major clinical outcome of patients 3 months after disease onset. Disease outcome was also examined by analyzing symptom improvement at discharge. In particular, mortality and symptomatic intracranial hemorrhage (sICH) were evaluated as risk factors.RESULTS This study included 21 patients who received thrombolysis, 36 patients receiving thrombectomy, and 32 patients receiving conventional treatment. Among these 3 treatments, only the thrombectomy group clearly showed the most encouraging clinical outcome (mRS score 0–2; p < 0.05, Fisher’s exact test) and marked improvement (OR 25.84, 95% CI 2.44–273.59) compared with conventional treatment. It is noteworthy that the mortality rate of the thrombectomy and thrombolysis group was similar to that of the conventional group, and thrombectomy and thrombolysis increased the risk of sICH in comparison with conventional care (p < 0.05, Fisher’s exact test).CONCLUSIONS Patients with AIS and ASPECTS < 6 definitely benefited from thrombectomy with higher sICH risk, whereas thrombolysis management showed similar efficacy to the control group.https://thejns.org/doi/abs/10.3171/2017.11.JNS171297KEYWORDS acute ischemic stroke; thrombectomy; ASPECTS; large infarcts; vascular disorders; thrombolysis

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Heart Association/American Stroke Association (AHA/ASA) Stroke Council recommended that thrombectomy should be followed by thrombolysis treatment as an early management strategy for patients with AIS and large-ves-sel occlusion.19

CT and MR images are very useful tools for evaluat-ing the infarct lesion of the brain. It is the general con-sensus that the Alberta Stroke Program Early CT Score (ASPECTS) is a reliable and useful grading system for standardized quantification of CT images.1 The low grad-ing of ASPECTS suggests a large, diffuse, ischemic terri-tory of the middle cerebral artery (MCA), and the baseline ASPECTS is a predictor of clinical outcome.6,27 Because the low ASPECTS evaluation is critical to determine poor outcome in patients managed by reperfusion therapies, the updated AHA/ASA guidelines use the selection criteria for thrombectomy therapy as ASPECTS ≥ 6.19 However, the benefit from endovascular therapy in patients with AIS and ASPECTS < 6 remains uncertain. Thus, the data from the patients with poor ASPECTS (< 6) are needed for esti-mating the efficacy of endovascular thrombectomy.

In the present study, we reviewed and analyzed clini-cal data of patients with AIS treated by thrombectomy or thrombolysis that were recorded and collected in the two medical centers. To compare the efficacy of different ther-apies in patients with ASPECTS < 6, we selected the pa-tients who were treated by endovascular intervention or by thrombolysis. We compared the major disease outcome, the modified Rankin Scale (mRS) score at 3 months after treatment, and the symptomatic improvement at discharge in the patients receiving endovascular intervention or IV thrombolysis versus conventional treatment. We also com-pared the data of symptomatic intracranial hemorrhage (sICH) at 24 hours after treatment as well as the mortality rate of patients managed by thrombolysis versus throm-bectomy with the rate in conventional treatment.

MethodsPatients and Selection

This retrospective study was approved by the Eth-ics Committee of Xinhua Hospital, Shanghai Jiao Tong University, and the Ethics Committee of the First People’s Hospital of Changzhou, Soochow University. There were 13,285 stroke patients who were hospitalized at Xinhua Hospital or The First People’s Hospital of Changzhou from December 2010 to May 2015 who were included in this study. Among these selected patients, 396 received IV thrombolysis management, 98 received endovascular mechanical thrombectomy, and 12,791 were treated by conventional procedures with neither thrombolysis nor thrombectomy. Due to insufficient clinical data and our specific requirement of patient selection (ASPECTS < 6, National Institutes of Health Stroke Scale [NIHSS] score ≥ 10, anterior artery occlusion, and age < 80 years), the final results reported in the present study include a total of 89 consecutive patients. Among these patients, 36 were in the endovascular thrombectomy group, 21 in the IV throm-bolysis group, and 32 in the conventional care group. The detailed screening processes are shown in Fig. 1.

The patients’ clinical data were carefully recorded, in-

cluding age, sex, NIHSS score at admission and discharge, cause of stroke, symptom of hemorrhage, time from onset to presentation or management, blood pressure, blood glu-cose level, serum lipid and cholesterol levels, and medi-cal history (such as atrial fibrillation, hypertension, and diabetes). As the ASPECTS criteria were not added into the treatment guideline of our two centers, the ASPECTS was not measured immediately after CT angiography and did not affect the choice of management strategy. The ASPECTS were evaluated by two neurosurgeons at the initial stage of this retrospective study (C.-J.G., Y.L., M.C., and Y.P. contributed to this work). The ASPECTS of 15 patients given by these two neurosurgeons were inconsis-tent, and a third opinion was requested. Intracranial hem-orrhagic transformations in 24 hours were determined by two clinical phenotypes, silent or symptomatic, and then classified into different categories. Hemorrhage was scored by using the Pessin criteria and formalized in the European Cooperative Acute Stroke Study trials (hemor-rhagic infarction, types 1 and 2; parenchymal hematoma, types 1 and 2).9,10,18 Symptomatic intracranial hemorrhage was defined as any parenchymal hematoma, subarachnoid hemorrhage, or intraventricular hemorrhage associated with the NIHSS score by 4 or more within 24 hours.20 The mRS score was measured by the attending neurosurgeons at 90 days, or recorded when the end point event (death) occurred. The characterizations for mRS were obtained by telephone follow-up or from the records of reexamina-tion at 3 months. Functional dependence was defined as a score of 3–6 on the mRS at 90 days. Functional inde-pendence was defined as a score of 0–2 on the mRS at 90 days. The conventional care group enrolled patients who were subject to high risks during thrombolysis or throm-bectomy, or when families of the patients refused to allow thrombolysis or thrombectomy, and when the onset to ad-mission time was within 6 hours.

Patient Treatment ProcessesThe patients in the thrombectomy group were treated

as described previously.11 Briefly, on admission, a stroke neurologist examined all patients clinically; cranial CT or multimodal MR angiography was performed prior to every intervention to confirm the diagnosis of large-vessel occlusion and to rule out ICH. Interventional treatment was initiated within the first 6 hours from the onset of stroke. Technical details of the endovascular procedure were described in a previous study.12 The main processes included transfemoral access with a 6-Fr sheath (Terumo Radifocus Introducer) into the right femoral artery, and conventional cerebral angiography showing the location of the occlusion and collateral circulation. Then, a Rebar 18 microcatheter (eV3) was navigated through the throm-bus with a microwire, and the Solitaire stent (eV3) was deployed in the clot and allowed to remain in place for 2–3 minutes. The entire system, consisting of the stent and the microcatheter, was completely retrieved. After retrieval, the clot typically could be seen entangled within the mesh-work of the stent, and control angiography was performed following each retrieval until success. The femoral sheath was removed and the wound closed with an Angio-Seal (St. Jude Medical, Inc.) vascular closure device.


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For thrombolysis treatment, we followed the AHA guideline.5 Briefly, a clinical stroke neurologist checked the patients with AIS to verify there were no contraindica-tions for thrombolysis, such as systolic/diastolic > 200/120 mm Hg, active hemorrhage or intracranial tumors, ce-rebral vascular malformations, surgery within 2 weeks, receiving oral anticoagulation medication, or bleeding diathesis with severe heart, liver, or kidney substantive organ diseases, and confirmed the onset time within 4.5 hours. Patients were given alteplase at a dose of 0.9 mg/kg weight, and the maximum dosage was 90 mg. While 10% of the total dosage was injected intravenously, the remain-ing dose of alteplase was infused within 1 hour. Within 24 hours after thrombectomy or thrombolysis, administration of anticoagulants or antiplatelet agents was prohibited. Af-ter 24 hours, if there was no intracranial hemorrhage, an-tiplatelet or anticoagulant therapy was used.

In the conventional care group, patients were given lipid-lowering drugs orally, such as atorvastatin calcium. All conventional care patients without intracranial hemor-rhage received anticoagulation treatment after admission examination. The CT scan was reviewed during hospital-

ization; if intracranial hemorrhage occurred, anticoagu-lation therapy was terminated and the treatment regimen adjusted. No extra thrombolysis or thrombectomy man-agement was performed on conventional care patients.

Statistical AnalysisWe present the baseline variables as means and SDs,

or medians and ranges, and variables as percentages. For comparisons between different therapies (thrombolysis vs conventional care, and thrombectomy vs conventional care) and outcomes, we used a 2-sided Fisher’s exact test; significance was set as p < 0.05. The associations between different management options and symptomatic improve-ment or some other risk events were analyzed by multi-variable logistic regression analysis. We also adjusted the odds ratio (OR) and secondary effects factors for potential imbalance in major prognostic variables. The parameters involved in adjustment were age, occluded vessel, NIHSS admission score, plasma glucose level, atrial fibrillation, and diabetes. We report ORs with 95% confidence inter-vals (CIs). All statistical analyses were performed using SAS software (version 9.4, SAS Institute).

FIG. 1. Flow chart of patient screening. This figure illustrates the patient selection criteria. The 13,285 patients hospitalized with AIS were divided into 3 groups according to the management type received. The NIHSS score (NIHSSS), occlusion site, follow up, patient age, and ASPECTS were the screening criteria.


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ResultsBecause the efficacy of reperfusion management in

patients with AIS and large infarcts is uncertain, we ex-plored the clinical significance of cases with ASPECTS < 6 in two stroke management centers and analyzed the outcomes of different treatments.

Characteristics of the Patients and StratificationFrom December 2010 to May 2015, 13,285 stroke pa-

tients were admitted to Xinhua Hospital and The First People’s Hospital of Changzhou. For this retrospective study, we screened these patients as presented in Fig. 1 (the main screening criteria were detailed in the Meth-ods). After screening, there were 89 patients in 3 differ-ent management methods. In these 89 patients, 21 patients received IV r-tPA thrombolysis treatment (thrombolysis group), 36 patients underwent endovascular thrombecto-my treatment (thrombectomy group), and the remaining 32 patients were managed by conventional care without IV r-tPA treatment or thrombectomy (control group). The

mean ages of these 3 groups ranged from 60 to 70 years (average age for thrombolysis was 66.19 years, for throm-bectomy 60.83, and for control 63.13; Table 1). Whereas 48% of male patients were included in the thrombolysis group, 53% were male in the thrombectomy group, and 56% in the conventional care group. The main vascular occlusions were in the MCA. There were 100%, 72%, and 88% of patients with an occluded MCA in the thrombol-ysis group, thrombectomy group, and conventional care group, respectively. Nearly half of the patients’ symptoms were caused by large artery atherosclerosis in the throm-bectomy (36%) or thrombolysis (53%) groups, while 81% of stroke cases resulted from large artery atherosclerosis in the conventional care group. Stroke causes were car-diogenic embolism in 43% of thrombolysis-managed pa-tients, 53% of thrombectomy-treated patients, and 13% of conventional care patients. The detailed baseline charac-teristics of these three groups are listed in Table 1.

The major outcome variable, mRS score at 3 months, was compared between the thrombectomy group (or thrombolysis group) and the conventional care group.

TABLE 1. Baseline characteristics

Variable

Treatment Group p ValueThrombolysis

(n = 21)Thrombectomy

(n = 36)Control (n = 32)

Thrombolysis vs Control

Thrombectomy vs Control

Males, no. (%) 10 (48) 19 (53) 18 (56) 0.584 0.811Atrial fibrillation, no. (%) 9 (43) 19 (53) 5 (16) 0.054 0.002Hypertension, no. (%) 13 (62) 18 (50) 21 (66) 1.000 0.226Diabetes, no. (%) 3 (14) 7 (19) 14 (44) 0.035 0.038Mean age ± SD (yrs) 66.19 ± 6.79 60.83 ± 14.22 63.13 ± 12.30 0.249 0.482Mean ASPECTS ± SD On admission 4.10 ± 1.09 3.06 ± 1.47 3.13 ± 1.70 0.025 0.857 After 24 hrs 2.00 ± 1.82 1.64 ± 1.73 2.72 ± 2.14 0.211 0.250Mean NIHSSS ± SD on admission 15.38 ± 3.88 19.67 ± 3.41 17.91 ± 6.60 0.120 0.182Mean systolic ± SD (mm Hg) 147.8 ± 20.6 142.0 ± 30.1 145.63 ± 23.7 0.927 0.619Mean diastolic ± SD (mm Hg) 80.5 ± 14.0 83.3 ± 15.9 78.9 ± 14.9 0.716 0.245Mean plasma glucose ± SD (mM) 7.93 ± 2.73 9.02 ± 4.37 10.00 ± 4.51 0.079 0.228Mean total cholesterol ± SD (mM) 4.59 ± 1.10 4.52 ± 0.77 4.56 ± 1.07 0.976 0.979Mean total triacylglycerol ± SD (mM) 1.49 ± 1.24 1.90 ± 1.05 1.52 ± 0.70 0.093 0.158Mean LDL-C ± SD (mM) 2.72 ± 0.69 2.12 ± 0.49 2.74 ± 0.76 0.961 <0.001Occluded vessel, no. (%)* 0.143 0.120 MCA_M1 18 (86) 24 (67) 15 (47) MCA_M2 3 (14) 2 (5) 13 (41) ICA 0 1 (3) 3 (9) Tandem occlusion 0 9 (25) 1 (3)Stroke cause, no. (%)† 0.012 <0.001 Cardiogenic embolism 9 (43) 19 (53) 4 (13) Large-artery atherosclerosis 11 (52) 13 (36) 26 (81) Other 1 (5) 3 (8) 0 Undetermined 0 1 (3) 2 (6)

ICA = internal carotid artery; LDL-C = low-density lipoprotein cholesterol; MCA_M1 = M1 segment of MCA; MCA_M2 = M2 segment of the MCA; tandem occlusion = ICA in tandem with MCA occlusion.* MCA_M1 and MCA_M2 were merged into one group, ICA and tandem occlusion were merged into one group, and a chi-square test was performed.† Large-artery atherosclerosis, other, and undetermined were merged into one group, then a chi-square test was performed.



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Considering that ASPECTS are generally negatively cor-related with NIHSS scores,15 we also checked symptom improvement after different management techniques. To estimate how much symptoms improved after treatment, we compared the clinical improvement (discharge NIHSS score - admission NIHSS score ≥ 4) and marked improve-ment (discharge NIHSS score - admission NIHSS score ≥ 10) rate of patients treated by endovascular intervention or IV thrombolysis with conventional care. The difference in sICH and mortality risk between thrombectomy (or thrombolysis) and conventional care was also estimated.

OutcomesSix (17%) of 36 patients achieved functional indepen-

dence (mRS score ≤ 2 at 3 months) in the thrombectomy group, whereas there were no functionally independent patients in either the IV thrombolysis group or the con-ventional care group at 3 months after treatment (Fig. 2, Table 2). The favorable outcome rate (mRS score ≤ 2 at 3 months) of the thrombectomy group was higher than that of the conventional care group, with statistical signifi-cance (p = 0.026, Fisher’s exact test; Table 2). It is note-worthy that the distribution of mRS scores at 3 months in the IV thrombolysis group was very similar to that in the conventional care group (Fig. 2).

The clinical improvement rate of the thrombolysis group was 71% (15 of 21 patients), which was higher than that in the conventional care group (adjusted OR 14.62, 95% CI 2.77–77.20; unadjusted OR 10.83, 95% CI 2.96–39.66; Supplemental Table I). Twenty-eight (78%) of 36 patients clinically improved after endovascular interven-tion (Supplemental Figure I), and also showed an elevated clinical improvement rate compared with the conven-tional care group (adjusted OR 21.75, 95% CI 4.7–113.38; unadjusted OR 15.17, 95% CI 4.63–49.63; Supplemental Table I).

Clinical signs in 44% (16 of 36) of thrombectomy-man-aged patients and in 14% (3 of 21) of IV thrombolysis-treated patients markedly improved at discharge (Table 3). Correspondingly, only 1 (3%) of 32 patients in the con-ventional care group achieved marked symptomatic im-

provement at discharge. The marked improvement rate in the thrombectomy group was higher when compared with the conventional care group (adjusted OR 25.84, 95% CI 2.44–273.59; unadjusted OR 24.8, 95% CI 3.05–201.92), whereas IV thrombolysis treatment did not show obvious advantages over the conventional care group (adjusted OR 4.31, 95% CI 0.34–55.13; unadjusted OR 5.17, 95% CI 0.5–53.45; Table 3).

Mortality and sICHThe mortality rates of the three groups were approxi-

mately 40% (control 41% [13/32], thrombolysis 48% [10/21], and thrombectomy 33% [12/26]; Supplemental Table II). Symptoms of intracranial hemorrhage during therapy are risk factors for disability outcome. There were 7 (19%) and 4 (19%) patients who suffered sICH during or 24 hours after treatment in the thrombectomy and thrombolysis groups, respectively, whereas no sICH (0%) occurred 24 hours after conventional care (Table 4). The sICH was more frequent in the thrombectomy and throm-bolysis groups when compared with the conventional care group (thrombectomy vs conventional care, p = 0.012, thrombolysis vs conventional care, p = 0.020, Fisher’s ex-act test; Table 4).

DiscussionAIS is a serious, harmful, acute disease. Presently,

IV thrombolysis, endovascular thrombectomy, and con-ventional treatment are the major therapies for this dis-

TABLE 2. Comparison of the major outcome variable (mRS score) among different therapies and conventional management

Group mRS score ≤2 (%) mRS score >2 (%) p Value

Thrombolysis 0 (0) 21 (100) —Thrombectomy 6 (17) 30 (83) 0.026*Control 0 (0) 32 (100) —

* Analysis performed using a 2-sided Fisher’s exact test.

FIG. 2. Outcomes of patients managed by different therapies. The numbers and percentages of patients in the management cohorts indicate the distribution of mRS scores.


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ease. Endovascular thrombectomy, as a new management method, could more quickly achieve recanalization than other therapies. It is generally believed that AIS patients with ASPECTS ≥ 6 strikingly benefited from endovascu-lar thrombectomy, especially by using a third-generation stent.2,4,6,8,13,21 However, there is a significant controversy concerning whether patients with ASPECTS < 6 should be subjected to endovascular thrombectomy.19 In this study, we retrospectively compared the outcome and risk of three moderately severe and severe AIS patient groups (NIHSS score ≥ 10 and ASPECTS < 6) that were managed by en-dovascular thrombectomy, IV thrombolysis, and conven-tional care. Only the thrombectomy group showed better favorable outcome rates and an elevated marked improve-ment rate when compared with the conventional care group. The postoperative sICH risk in 24 hours was higher in the thrombectomy and IV thrombolysis groups in com-parison to the conventional care group, and the mortality rates of these 3 groups were similar.

Because patients with large ischemic infarcts lesion have been excluded in most thrombectomy clinical trials, the benefits of endovascular therapy in these patients with ASPECTS < 6 remains uncertain.19 A recent MR CLEAN (Multicenter Randomized Clinical Trial of Endovascu-lar Treatment for Acute Ischemic Stroke in the Nether-lands) trial enrolled the AIS patients with large infarcts (ASPECTS 0–5) and analyzed the effects of ASPECTS on efficacy of intraarterial treatment. However, these in-vestigators still did not give us a clear answer for whether endovascular intervention improved the mRS score of pa-tients with large infarcts at 3 months, because the sample size was too small.26 In our study, the sample size (68 pa-tients with ASPECTS 0–5) was more than twice that of the MR CLEAN trial (30 patients with ASPECTS 0–4) in the thrombectomy and conventional care groups. Un-like MR CLEAN, our analysis showed intraarterial treat-ment improved the mRS scores of patients with large in-farcts at 3 months with statistical significance. Not only was this found in the long-term outcome (3 months), but

it also showed a higher symptomatic improvement rate in the thrombectomy group than in the conventional care group in our study. This strongly indicated that endovas-cular thrombectomy might be beneficial for improving the outcomes of patients with AIS and large infarcts. Interest-ingly, when patients were managed by conventional care, there was no functional independent recovery in patients with large infarcts in either our study or the MR CLEAN trial.26 This suggested that conventional treatment might not be helpful for patients with large infarcts recovering to a functional independent state in 3 months.

For patients managed using IV thrombolysis, there was no benefit of a functional independent recovery from ther-apy when compared with conventional care. The same lack of favorable outcome for patients treated using injec-tion of alteplase or conventional care was the convincing evidence of a poor benefit for IV thrombolysis. With re-spect to the outcome at 3 months, the proportions of mRS scores of 3, 4, or 5, and deceased patients, were nearly con-sistent between the thrombolysis group and conventional care group. Additionally, there was no statistically sig-nificant marked symptomatic improvement at discharge in patients administrated r-tPA when compared with patients who received conventional care. The previous studies also showed that low ASPECTS (< 6) was an independent pre-dictor for a poor outcome after IV thrombolysis.16,24 This finding supports the idea that patients with ASPECTS 0–5 would hardly benefit from alteplase injection. Therefore, endovascular thrombectomy appears to be the only fea-sible therapy for managing patients with AIS and unfavor-able ASPECTS (< 6) to achieve good outcome.

Reperfusion of ischemic brain tissues might increase to intracranial hemorrhage, and a low ASPECTS was frequently associated with sICH during management.14,22 The sICH rate was increased to nearly 20% in reperfusion management groups, in patients with low ASPECTS. The sICH often occurred in patients who were managed by conventional care beyond 24 hours after treatment. There-fore, the total sICH rate in conventional care patients was also at a high level before discharge. Because sICH is a strong predictor for poor outcome, this high sICH rate in patients with low ASPECTS might partially explain why the efficacy of thrombolysis or thrombectomy became worse in these patients.

Limitations of the StudyAs this is a retrospective analysis, we could not keep all

baseline factors balanced. These unbalanced factors, such as incidence of diabetes and stroke etiology, might bias the results. However, not only did we acquire the clinical

TABLE 3. Comparison of marked improvement among different therapies and usual management

Group Non-Marked Improvement (%) Marked Improvement (%) Unadjusted OR (95% CI) Adjusted OR (95% CI)*

Thrombolysis 18 (86) 3 (14) 5.17 (0.50–53.45) 4.31 (0.34–55.13)Thrombectomy 20 (56) 16 (44) 24.80 (3.05–201.92) 25.84 (2.44–273.59)Control 31 (97) 1 (3) 1.00 1.00

* Determined using logistic regression; the adjusted variables were age, occluded vessel, NIHSS admission score, plasma glucose level, atrial fibrillation, and diabetes.

TABLE 4. Comparison of sICH among different therapies and conventional management

Group No sICH (%) sICH (%) p Value*

Thrombolysis 17 (81) 4 (19) 0.020Thrombectomy 29 (81) 7 (19) 0.012Control 32 (100) 0 (0) —

* Value obtained using a 2-sided Fisher’s exact test.



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data properly according to the criteria as noted above, but we have also carefully analyzed and verified the patient’s condition selected for generating all the provided data. Another limitation of the study is the small sample size; we could not analyze which features the patients benefited from during endovascular interventional therapy.

ConclusionsIn patients with large ischemic infarcts (ASPECTS < 6),

mechanical thrombectomy showed advantages, although it increased the sICH risk within 24 hours when compared with conventional care. The efficacy of IV thrombolysis was similar to that of conventional care management, but with a higher sICH risk.

AcknowledgmentsThis study is supported by a 2013–2014 National Clinical Key

Specialty Construction Project, Key Issues In Emergency and Pre-Hospital Emergency Medical Hospital Cohesion (grant no. SHDC2015649 [to Dr. Pan]), Integration of Severe Trauma Hos-pital Treatment Technology Research and Promotion (grant no. 2015XH010 [to Dr. Pan]), and the National Natural Science Foun-dation of China (grant no. 81300994 [to Dr. Jing]).

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DisclosuresThe authors report no conflict of interest concerning the materi-als or methods used in this study or the findings specified in this paper.

Author ContributionsConception and design: Pan, Jiang, Peng, Jing. Acquisition of data: Peng, Jing. Analysis and interpretation of data: Jiang, Jing. Drafting the article: Jiang, Peng, Fei. Critically revising the article: Jiang. Reviewed submitted version of manuscript: Peng. Approved the final version of the manuscript on behalf of all authors: Pan. Statistical analysis: Fei, Wang, Chen. Administra-tive/technical/material support: Wang, Gao, Li. Study supervision: Pan, Gao, Chen, Li.

Supplemental Information Online-Only ContentSupplemental material is available with the online version of the article.

Supplemental Figure and Tables. https://thejns.org/doi/suppl/ 10.3171/2017.11.JNS171297.

CorrespondenceShuming Pan: Xinhua Hospital, Shanghai, China. [email protected].




endovascular thrombectomy can be beneficial to acute

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