National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland.
Department of Neurology, MedStar Georgetown University Hospital, Washington, DC.
JAMA Neurol. 2024 Oct 1;81(10):1085-1093. doi: 10.1001/jamaneurol.2024.2500.
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.
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.
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.
最近，6 项随机临床试验——RESCUE-Japan-LIMIT（超急性脑栓塞血管内挽救的恢复-日本大缺血核心试验）、ANGEL-ASPECT（急性缺血性卒中大梗死血管内治疗试验）、SELECT2（大缺血性卒中介入取栓试验）、TESLA（急性前循环大缺血性卒中血栓切除术）、TENSION（大梗死溶栓治疗急性缺血性卒中）和 LASTE（大卒中治疗评价）——已经结束了对血管内血栓切除术（EVT）治疗前循环大血管闭塞和大面积缺血性改变患者的疗效和安全性的研究，这些患者的定义为 Alberta Stroke Program Early Computed Tomography Score（ASPECTS）评分为 5 或更低。总体而言，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，有 1 项试验接近失败。然而，关于如何解释和将这些试验结果纳入常规临床实践，仍存在一些问题。
在这项已发表试验的叙述性综述和分析中，确定了现有临床数据的重要细微差别，并强调了一些挥之不去的不确定性领域，包括低 ASPECTS 评分的患者在晚期治疗窗口和大核心体积患者中 EVT 的疗效和安全性。还强调了在为低 ASPECTS 评分的选择患者做出 EVT 治疗决策时，如灌注和磁共振成像等高级神经影像学的可能重要作用。
最近的试验数据提供了强有力的证据，证明 EVT 对前循环大血管闭塞性卒中和低 ASPECTS 评分的患者是安全有效的，这些患者在卒中发病后 6 小时内接受治疗。然而，尽管进行了 EVT 治疗，患者的预后往往仍然较差。低 ASPECTS 评分的患者在卒中发病后 6 小时以上接受 EVT 的疗效和安全性仍不确定，目前的试验数据似乎太少，不能证明在这个延长的时间窗口内放弃高级卒中成像。此外，对于大核心体积（100ml 或更大）或 M2 闭塞（即大脑中动脉第二段闭塞）的患者，EVT 的疗效和安全性仍不确定。需要进一步研究以更好地识别可能对 EVT 有明显反应的患者，从而进一步优化卒中分诊流程和医疗资源利用。
