Outcomes of Mechanical Thrombectomy for Patients With ...

This cohort study uses data from the Stroke Thrombectomy and Aneurysm ... with a score of 10 indicating normal and 0 indicating ischemic ... OutcomesofMechanicalThrombectomyforPatientsWithStrokePresentingWithLowAlbertaStrokeProgramEarlyComputedTomographyScoreintheEarlyandExtendedWindow|CerebrovascularDisease|JAMANetworkOpen|JAMANetwork Ourwebsiteusescookiestoenhanceyourexperience.Bycontinuingtouseoursite,orclicking"Continue,"youareagreeingtoourCookiePolicy | Continue [SkiptoNavigation] fulltexticon FullText contentsicon Contents figureicon Figures/Tables multimediaicon Multimedia attachicon SupplementalContent referencesicon References relatedicon Related commentsicon Comments DownloadPDF Comment TopofArticle KeyPoints Abstract Introduction Methods Results Discussion Conclusions ArticleInformation References Table1. CharacteristicsofPatientsWhoUnderwentMechanicalThrombectomyPresentingWithICAorM1OcclusionViewLargeDownloadTable2. CharacteristicsofPatientsWhoUnderwentMechanicalThrombectomyPresentingWithICAorM1OcclusionandanASPECTSof2to5WhoHadSuccessfulvsUnsuccessfulRecanalizationViewLargeDownloadTable3. CharacteristicsofPatientsWhoUnderwentMechanicalThrombectomyPresentingWithICAorM1OcclusionandanASPECTSof2to5WhoPresentedintheEarlyvsExtendedWindowViewLargeDownload Supplement1.eTable.MultivariableRegressionAnalysisforPredictorsof90-DaymRS0-3 Supplement2.NonauthorCollaborators 1.Powers  WJ,Rabinstein  AA,Ackerson  T,  etal. Guidelinesfortheearlymanagementofpatientswithacuteischemicstroke:2019updatetothe2018guidelinesfortheearlymanagementofacuteischemicstroke:aguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociation/AmericanStrokeAssociation.  Stroke.2019;50(12):e344-e418.doi:10.1161/STR.0000000000000211PubMedGoogleScholarCrossref2.Jovin  TG,Chamorro  A,Cobo  E,  etal;REVASCATTrialInvestigators. Thrombectomywithin8hoursaftersymptomonsetinischemicstroke.  NEnglJMed.2015;372(24):2296-2306.doi:10.1056/NEJMoa1503780PubMedGoogleScholarCrossref3.Nogueira  RG,Jadhav  AP,Haussen  DC,  etal;DAWNTrialInvestigators. Thrombectomy6to24hoursafterstrokewithamismatchbetweendeficitandinfarct.  NEnglJMed.2018;378(1):11-21.doi:10.1056/NEJMoa1706442PubMedGoogleScholarCrossref4.Goyal  M,Menon  BK,vanZwam  WH,  etal;HERMEScollaborators. Endovascularthrombectomyafterlarge-vesselischaemicstroke:ameta-analysisofindividualpatientdatafromfiverandomisedtrials.  Lancet.2016;387(10029):1723-1731.doi:10.1016/S0140-6736(16)00163-XPubMedGoogleScholarCrossref5.Albers  GW,Marks  MP,Kemp  S,  etal;DEFUSE3Investigators. Thrombectomyforstrokeat6to16hourswithselectionbyperfusionimaging.  NEnglJMed.2018;378(8):708-718.doi:10.1056/NEJMoa1713973PubMedGoogleScholarCrossref6.Powers  WJ,Derdeyn  CP,Biller  J,  etal;AmericanHeartAssociationStrokeCouncil. 2015AmericanHeartAssociation/AmericanStrokeAssociationfocusedupdateofthe2013GuidelinesfortheEarlyManagementofPatientsWithAcuteIschemicStrokeRegardingEndovascularTreatment:aguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociation/AmericanStrokeAssociation.  Stroke.2015;46(10):3020-3035.doi:10.1161/STR.0000000000000074PubMedGoogleScholarCrossref7.Barber  PA,Hill  MD,Eliasziw  M,  etal;ASPECTSStudyGroup. Imagingofthebraininacuteischaemicstroke:comparisonofcomputedtomographyandmagneticresonancediffusion–weightedimaging.  JNeurolNeurosurgPsychiatry.2005;76(11):1528-1533.doi:10.1136/jnnp.2004.059261PubMedGoogleScholarCrossref8.Román  LS,Menon  BK,Blasco  J,  etal;HERMEScollaborators. Imagingfeaturesandsafetyandefficacyofendovascularstroketreatment:ameta-analysisofindividualpatient-leveldata.  LancetNeurol.2018;17(10):895-904.doi:10.1016/S1474-4422(18)30242-4PubMedGoogleScholarCrossref9.Kidwell  CS,Wintermark  M,DeSilva  DA,  etal. MultiparametricMRIandCTmodelsofinfarctcoreandfavorablepenumbralimagingpatternsinacuteischemicstroke.  Stroke.2013;44(1):73-79.doi:10.1161/STROKEAHA.112.670034PubMedGoogleScholarCrossref10.Mourand  I,Abergel  E,Mantilla  D,  etal. FavorablerevascularizationtherapyinpatientswithASPECTS≤5onDWIinanteriorcirculationstroke.  JNeurointervSurg.2018;10(1):5-9.doi:10.1136/neurintsurg-2017-013358PubMedGoogleScholarCrossref11.Kaesmacher  J,Chaloulos-Iakovidis  P,Panos  L,  etal. MechanicalthrombectomyinischemicstrokepatientswithAlbertaStrokeProgramEarlyComputedTomographyScore0-5.  Stroke.2019;50(4):880-888.doi:10.1161/STROKEAHA.118.023465PubMedGoogleScholarCrossref12.Cagnazzo  F,Derraz  I,Dargazanli  C,  etal. MechanicalthrombectomyinpatientswithacuteischemicstrokeandASPECTS≤6:ameta-analysis.  JNeurointervSurg.2020;12(4):350-355.doi:10.1136/neurintsurg-2019-015237PubMedGoogleScholarCrossref13.Hungerford  JP,Hyer  M,Turk  AS,  etal. ImpactofASPECTscoresandinfarctdistributiononoutcomesamongpatientsundergoingthrombectomyforacuteischemicstrokewiththeADAPTtechnique.  JNeurointervSurg.2017;9(9):823-829.doi:10.1136/neurintsurg-2016-012528PubMedGoogleScholarCrossref14.Spiotta  AM,Vargas  J,Hawk  H,  etal. ImpactoftheASPECTscoresanddistributiononoutcomeamongpatientsundergoingthrombectomyforacuteischemicstroke.  JNeurointervSurg.2015;7(8):551-558.doi:10.1136/neurintsurg-2014-011195PubMedGoogleScholarCrossref15.Goyal  M,Demchuk  AM,Menon  BK,  etal;ESCAPETrialInvestigators. Randomizedassessmentofrapidendovasculartreatmentofischemicstroke.  NEnglJMed.2015;372(11):1019-1030.doi:10.1056/NEJMoa1414905PubMedGoogleScholarCrossref16.Rebchuk  AD,O’Neill  ZR,Szefer  EK,Hill  MD,Field  TS. HealthutilityweightingofthemodifiedRankinScale:asystematicreviewandmeta-analysis.  JAMANetwOpen.2020;3(4):e203767.doi:10.1001/jamanetworkopen.2020.3767PubMedGoogleScholar17.Yoo  AJ,Berkhemer  OA,Fransen  PSS,  etal;MRCLEANinvestigators. EffectofbaselineAlbertaStrokeProgramEarlyCTScoreonsafetyandefficacyofintra-arterialtreatment:asubgroupanalysisofarandomisedphase3trial(MRCLEAN).  LancetNeurol.2016;15(7):685-694.doi:10.1016/S1474-4422(16)00124-1PubMedGoogleScholarCrossref18.Campbell  BCV,Majoie  CBLM,Albers  GW,  etal;HERMEScollaborators. Penumbralimagingandfunctionaloutcomeinpatientswithanteriorcirculationischaemicstroketreatedwithendovascularthrombectomyversusmedicaltherapy:ameta-analysisofindividualpatient-leveldata.  LancetNeurol.2019;18(1):46-55.doi:10.1016/S1474-4422(18)30314-4PubMedGoogleScholarCrossref19.Sarraj  A,Hassan  AE,Grotta  J,  etal. Optimizingpatientselectionforendovasculartreatmentinacuteischemicstroke(SELECT):aprospective,multicentercohortstudyofimagingselection.  AnnNeurol.2020;87(3):419-433.doi:10.1002/ana.25669PubMedGoogleScholarCrossref20.Sabo  J,Chlan  LL,Savik  K. Relationshipsamongpatientcharacteristics,comorbidities,andvascularcomplicationspost-percutaneouscoronaryintervention.  HeartLung.2008;37(3):190-195.doi:10.1016/j.hrtlng.2007.06.001PubMedGoogleScholarCrossref21.Ciurică  S,Lopez-Sublet  M,Loeys  BL,  etal. Arterialtortuosity.  Hypertension.2019;73(5):951-960.doi:10.1161/HYPERTENSIONAHA.118.11647PubMedGoogleScholarCrossref22.Alawieh  A,Chatterjee  A,Feng  W,  etal. Thrombectomyforacuteischemicstrokeintheelderly:a‘realworld’experience.  JNeurointervSurg.2018;10(12):1209-1217.doi:10.1136/neurintsurg-2018-013787PubMedGoogleScholarCrossref23.Alawieh  A,Starke  RM,Chatterjee  AR,  etal. Outcomesofendovascularthrombectomyintheelderly:a“real-world”multicenterstudy.  JNeurointervSurg.2019;11(6):545-553.doi:10.1136/neurintsurg-2018-014289PubMedGoogleScholarCrossref24.Broocks  G,Kniep  H,Schramm  P,  etal. PatientswithlowAlbertaStrokeProgramEarlyCTScore(ASPECTS)butgoodcollateralsbenefitfromendovascularrecanalization.  JNeurointervSurg.2020;12(8):747-752.doi:10.1136/neurintsurg-2019-015308PubMedGoogleScholarCrossref25.Molad  JA,Findler  M,Auriel  E. Computedtomographyperfusion–baseddecisionmakingforacuteischemicstroke—missingthemismatch.  JStrokeCerebrovascDis.2017;26(5):e78-e79.doi:10.1016/j.jstrokecerebrovasdis.2017.03.001PubMedGoogleScholarCrossref26.Geuskens  RR,Borst  J,Lucas  M,  etal;MRCLEANtrialinvestigators. CharacteristicsofmisclassifiedCTperfusionischemiccoreinpatientswithacuteischemicstroke.  PLoSOne.2015;10(11):e0141571.doi:10.1371/journal.pone.0141571PubMedGoogleScholar27.Malhotra  K,Goyal  N,Katsanos  AH,  etal. Associationofbloodpressurewithoutcomesinacutestrokethrombectomy.  Hypertension.2020;75(3):730-739.doi:10.1161/HYPERTENSIONAHA.119.14230PubMedGoogleScholarCrossref28.Pallesen  LP,Barlinn  K,Puetz  V. Roleofdecompressivecraniectomyinischemicstroke.  FrontNeurol.2019;9(1119):1119.doi:10.3389/fneur.2018.01119PubMedGoogleScholar29.Jadhav  AP,Molyneaux  BJ,Hill  MD,Jovin  TG. Careofthepost-thrombectomypatient.  Stroke.2018;49(11):2801-2807.doi:10.1161/STROKEAHA.118.021640PubMedGoogleScholarCrossref SeeMoreAbout NeurologyRadiologySurgeryVascularSurgeryCerebrovascularDiseaseStrokeCerebrovascularInfarction SignUpforEmailsBasedonYourInterests SelectYourInterests CustomizeyourJAMANetworkexperiencebyselectingoneormoretopicsfromthelistbelow. AcidBase,Electrolytes,Fluids AddictionMedicine AllergyandClinicalImmunology Anesthesiology Anticoagulation ArtandImagesinPsychiatry BleedingandTransfusion Cardiology CaringfortheCriticallyIllPatient ChallengesinClinicalElectrocardiography ClinicalChallenge ClinicalDecisionSupport ClinicalImplicationsofBasicNeuroscience ClinicalPharmacyandPharmacology ComplementaryandAlternativeMedicine ConsensusStatements Coronavirus(COVID-19) CriticalCareMedicine CulturalCompetency DentalMedicine Dermatology DiabetesandEndocrinology DiagnosticTestInterpretation Diversity,Equity,andInclusion DrugDevelopment ElectronicHealthRecords EmergencyMedicine EndofLife EnvironmentalHealth Ethics FacialPlasticSurgery GastroenterologyandHepatology GeneticsandGenomics GenomicsandPrecisionHealth Geriatrics GlobalHealth GuidetoStatisticsandMedicine Guidelines HairDisorders HealthCareDeliveryModels HealthCareEconomics,Insurance,Payment HealthCareQuality HealthCareReform HealthCareSafety HealthCareWorkforce HealthDisparities HealthInequities HealthInformatics HealthPolicy Hematology HistoryofMedicine Humanities Hypertension ImagesinNeurology ImplementationScience InfectiousDiseases InnovationsinHealthCareDelivery JAMAInfographic LawandMedicine LeadingChange LessisMore LGBTQ LifestyleBehaviors MedicalCoding MedicalDevicesandEquipment MedicalEducation MedicalEducationandTraining MedicalJournalsandPublishing Melanoma MobileHealthandTelemedicine NarrativeMedicine Nephrology Neurology NeuroscienceandPsychiatry NotableNotes Nursing Nutrition Nutrition,Obesity,Exercise Obesity ObstetricsandGynecology OccupationalHealth Oncology OphthalmicImages Ophthalmology Orthopedics Otolaryngology PainMedicine PathologyandLaboratoryMedicine PatientCare PatientInformation Pediatrics PerformanceImprovement PerformanceMeasures PerioperativeCareandConsultation Pharmacoeconomics Pharmacoepidemiology Pharmacogenetics PharmacyandClinicalPharmacology PhysicalMedicineandRehabilitation PhysicalTherapy PhysicianLeadership Poetry PopulationHealth PreventiveMedicine ProfessionalWell-being Professionalism PsychiatryandBehavioralHealth PublicHealth PulmonaryMedicine Radiology RegulatoryAgencies Research,Methods,Statistics Resuscitation Rheumatology RiskManagement ScientificDiscoveryandtheFutureofMedicine SharedDecisionMakingandCommunication SleepMedicine SportsMedicine StemCellTransplantation Surgery SurgicalInnovation SurgicalPearls TeachableMoment TechnologyandFinance TheArtofJAMA TheArtsandMedicine TheRationalClinicalExamination Tobaccoande-Cigarettes Toxicology TraumaandInjury TreatmentAdherence Ultrasonography Urology Users'GuidetotheMedicalLiterature Vaccination VenousThromboembolism VeteransHealth Violence Women'sHealth WorkflowandProcess WoundCare,Infection,Healing Getthelatestresearchbasedonyourareasofinterest. WeeklyEmail MonthlyEmail SavePreferences PrivacyPolicy|TermsofUse OthersAlsoLiked Comment Limit200characters Limit25characters ConflictsofInterestDisclosure Identifyallpotentialconflictsofinterestthatmightberelevanttoyourcomment. Conflictsofinterestcomprisefinancialinterests,activities,andrelationshipswithinthepast3yearsincludingbutnotlimitedtoemployment,affiliation,grantsorfunding,consultancies,honorariaorpayment,speaker'sbureaus,stockownershiporoptions,experttestimony,royalties,donationofmedicalequipment,orpatentsplanned,pending,orissued. Erronthesideoffulldisclosure. Ifyouhavenoconflictsofinterest,check"Nopotentialconflictsofinterest"intheboxbelow.Theinformationwillbepostedwithyourresponse. Notallsubmittedcommentsarepublished.Pleaseseeourcommentingpolicyfordetails. Yes,Ihavepotentialconflictsofinterest. No,Idonothavepotentialconflictsofinterest. Limit140characters Limit3600charactersorapproximately600words Submit Thefollowinginformationisrequiredandmustbecompletedinordertosubmitacomment: ThankYou. Yourcommentsubmissionwassuccessful. Pleaseallowupto2businessdaysforreview,approval,andposting. ThisIssue Views 9,467 Citations 4 ViewMetrics DownloadPDF Twitter Facebook More LinkedIn Cite This Citation AlmallouhiE,AlKasabS,HubbardZ,etal.OutcomesofMechanicalThrombectomyforPatientsWithStrokePresentingWithLowAlbertaStrokeProgramEarlyComputedTomographyScoreintheEarlyandExtendedWindow.JAMANetwOpen.2021;4(12):e2137708.doi:10.1001/jamanetworkopen.2021.37708 Downloadcitationfile: Ris(Zotero) EndNote BibTex Medlars ProCite RefWorks ReferenceManager Mendeley ©2022 Permissions OriginalInvestigation Neurology December 8,2021 OutcomesofMechanicalThrombectomyforPatientsWithStrokePresentingWithLowAlbertaStrokeProgramEarlyComputedTomographyScoreintheEarlyandExtendedWindow Eyad Almallouhi, MD1,2;Sami AlKasab, MD1,2;Zachary Hubbard, MD1;etal EricC. Bass, DO3;Guilherme Porto, MD1;Ali Alawieh, MD,PhD4;Reda Chalhoub, BS1;PascalM. Jabbour, MD5;RobertM. Starke, MD6;StaceyQ. Wolfe, MD7;AdamS. Arthur, MD,MPH8;Edgar Samaniego, MD9;Ilko Maier, MD10;BrianM. Howard, MD4;Ansaar Rai, MD11;MinS. Park, MD12;Justin Mascitelli, MD13;Marios Psychogios, MD14;Reade DeLeacy, MD15;Travis Dumont, MD16;MichaelR. Levitt, MD17;Adam Polifka, MD18;Joshua Osbun, MD19;Roberto Crosa, MD20;Joon-Tae Kim, MD,PhD21;Walter Casagrande, MD22;Shinichi Yoshimura, MD,PhD23;Charles Matouk, MD24;PeterT Kan, MD25;RichardW Williamson, MD26;Benjamin Gory, MD,PhD27;Maxim Mokin, MD,PhD28;Isabel Fragata, MD,PhD29;Osama Zaidat, MD30;AlbertJ. Yoo, MD,PhD31;AlejandroM. Spiotta, MD1;fortheStrokeThrombectomyandAneurysmRegistry(STAR)Collaborators AuthorAffiliations ArticleInformation 1DepartmentofNeurosurgery,MedicalUniversityofSouthCarolina,Charleston 2DepartmentofNeurology,MedicalUniversityofSouthCarolina,Charleston 3DepartmentofRadiology,MedicalUniversityofSouthCarolina,Charleston 4DepartmentofNeurosurgery,EmoryUniversitySchoolofMedicine,Atlanta,Georgia 5DepartmentofNeurosurgery,ThomasJeffersonUniversityHospitals,Philadelphia,Pennsylvania 6DepartmentofNeurosurgery,UniversityofMiamiHealthSystem,Miami,Florida 7DepartmentofNeurosurgery,WakeForestSchoolofMedicine,Winston-Salem,NorthCarolina 8DepartmentofNeurosurgery,Semmes-MurpheyNeurologicandSpineClinic,UniversityofTennesseeHealthScienceCenter,Memphis 9DepartmentofNeurology,UniversityofIowaHospitalsandClinics,IowaCity 10DepartmentofNeurology,UniversityMedicalCenterGöttingen,Göttingen,Germany 11DepartmentofRadiology,WestVirginiaSchoolofMedicine,Morgantown 12DepartmentofNeurosurgery,UniversityofVirginia,Charlottesville 13DepartmentofNeurosurgery,UniversityofTexasHealthScienceCenteratSanAntonio,SanAntonio 14DepartmentofRadiology,UniversityofBasel,Basel,Switzerland 15DepartmentofNeurosurgery,MountSinaiHealthSystem,NewYork,NewYork 16DepartmentofNeurosurgery,UniversityofArizona,Tuscon 17DepartmentofNeurosurgery,UniversityofWashington,Seattle 18DepartmentofNeurosurgery,UniversityofFlorida,Gainesville 19DepartmentofNeurologicalSurgery,WashingtonUniversity,StLouis,Missouri 20DepartmentofNeurosurgery,EndovascularNeurologicalCenter,Montevideo,Uruguay 21DepartmentofNeurology,ChonnamNationalUniversityMedicalSchool,ChonnamNationalUniversityHospital,Gwangju,Korea 22DepartmentofCerebrovascularandEndovascularNeurosurgery,HospitalJuanFernandez,BuenosAires,Argentina 23DepartmentofNeurosurgery,HyogoCollegeofMedicine,Nishinomiya,Hyogo,Japan 24DepartmentofNeurosurgery,YaleSchoolofMedicine,NewHaven,Connecticut 25DepartmentofNeurosurgery,UniversityofTexasMedicalBranch,Galveston 26DepartmentofNeurosurgery,AlleghenyHealthNetwork,Pittsburgh,Pennsylvania 27DepartmentofDiagnosticandTherapeuticNeuroradiology,CentreHospitalierRégionalUniversitairedeNancy,Nancy,France. 28DepartmentofNeurosurgery,UniversityofSouthFlorida,Tampa 29NeuroradiologyDepartment,HospitalSãoJoséCentroHospitalar,Lisboa,Portugal 30NeuroscienceDepartment,BonSecoursMercyHealthStVincentMedicalCenter,Toledo,Ohio 31DepartmentofRadiology,TexasStrokeInstitute,Dallas–FortWorth JAMANetwOpen.2021;4(12):e2137708.doi:10.1001/jamanetworkopen.2021.37708 visualabstracticon VisualAbstract editorialcommenticon EditorialComment relatedarticlesicon RelatedArticles authorinterviewicon Interviews multimediaicon Multimedia KeyPointsQuestion  Whatisthe90-dayoutcomeforpatientswithstrokepresentingwithanAlbertaStrokeProgramEarlyComputedTomographyScore(ASPECTS)of2to5whounderwentmechanicalthrombectomy?Findings  Inthismulticentercohortstudyof2345patientspresentingwithanintracranialinternalcarotidarteryorM1occlusionwhounderwentmechanicalthrombectomy,213[9.1%]hadanASPECTSof2to5,and22%ofthesepatientsachievedfavorable90-dayoutcomes(modifiedRankinscalescoreof0-2).Patientswhoachievedsuccessfulrecanalizationwerenearly5timesmorelikelytoachievefavorableoutcomescomparedwithpatientswhohadunsuccessfulrecanalization.Meaning  ThisstudysuggeststhatpatientswithalowASPECTSonpresentationmayachieve90-dayfunctionalindependenceaftermechanicalthrombectomyiftheyachievesuccessfulrecanalization. Abstract Importance  Limiteddataareavailableabouttheoutcomesofmechanicalthrombectomy(MT)forreal-worldpatientswithstrokepresentingwithalargecoreinfarct.Objective  ToinvestigatethesafetyandeffectivenessofMTforpatientswithlargevesselocclusionandanAlbertaStrokeProgramEarlyComputedTomographyScore(ASPECTS)of2to5.Design,Setting,andParticipants  ThisretrospectivecohortstudyuseddatafromtheStrokeThrombectomyandAneurysmRegistry(STAR),whichcombinestheprospectivelymaintaineddatabasesof28thrombectomy-capablestrokecentersintheUS,Europe,andAsia.Thestudyincluded2345patientspresentingwithanocclusionintheinternalcarotidarteryorM1segmentofthemiddlecerebralarteryfromJanuary1,2016,toDecember31,2020.Patientswerefollowedupfor90daysafterintervention.TheASPECTSisa10-pointscoringsystembasedontheextentofearlyischemicchangesonthebaselinenoncontrastedcomputedtomographyscan,withascoreof10indicatingnormalandascoreof0indicatingischemicchangesinalloftheregionsincludedinthescore.Exposure  AllpatientsunderwentMTinoneoftheincludedcenters.MainOutcomesandMeasures  Amultivariableregressionmodelwasusedtoassessfactorsassociatedwithafavorable90-dayoutcome(modifiedRankinScalescoreof0-2),includinginteractiontermsbetweenanASPECTSof2to5andreceivingMTintheextendedwindow(6-24hoursfromsymptomonset).Results  Atotalof2345patientswhounderwentMTwereincluded(1175women[50.1%];medianage,72years[IQR,60-80years];2132patients[90.9%]hadanASPECTSof≥6,and213patients[9.1%]hadanASPECTSof2-5).At90days,47ofthe213patients(22.1%)withanASPECTSof2to5hadamodifiedRankinScalescoreof0to2(25.6%[45of176]ofpatientswhounderwentsuccessfulrecanalization[modifiedThrombolysisinCerebralIschemiascore≥2B]vs5.4%[2of37]ofpatientswhounderwentunsuccessfulrecanalization;P = .007).HavingalowASPECTS(oddsratio,0.60;95%CI,0.38-0.85;P = .002)andpresentingintheextendedwindow(oddsratio,0.69;95%CI,0.55-0.88;P = .001)wereassociatedwithworse90-dayoutcomeaftercontrollingforpotentialconfounders,withoutsignificantinteractionbetweenthese2factors(P = .64).ConclusionsandRelevance  Inthiscohortstudy,morethan1in5patientspresentingwithanASPECTSof2to5achieved90-dayfunctionalindependenceafterMT.Afavorableoutcomewasnearly5timesmorelikelyforpatientswithlowASPECTSwhohadsuccessfulrecanalization.TheassociationofalowASPECTSwith90-dayoutcomesdidnotdifferforpatientspresentingintheearlyvsextendedMTwindow. Introduction Clinicaltrialshaveshownthatmechanicalthrombectomy(MT)isassociatedwithimprovedfunctionaloutcomesforpatientswithacuteischemicstrokepresentingwithproximalanteriorcirculation,largevesselocclusion,andsalvageablebraintissue.1-5Asaresult,MThasbecomethestandardofcareforthesepatientssince2015.1,6TheAlbertaStrokeProgramEarlyComputedTomographyScore(ASPECTS)isa10-pointscoringsystembasedontheextentofearlyischemicchangesdetectedonthebaselinenoncontrastedcomputedtomographyscan,withascoreof10indicatingnormaland0indicatingischemicchangesinalloftheregionsincludedinthescore.7PatientswithanASPECTSlowerthan6wereexcludedfrommostclinicaltrials8;therefore,dataabouttheiroutcomesremainscarce,andwhetherthesepatientscouldstillachievebenefitsfromMTremainsunknown.4Therationalebehindexcludingthisgroupofpatientsstemsfromtheknowledgethatpatientswithalargecoreinfarctatpresentationareunlikelytobenefitfromreperfusiontothesamedegreeasthosewitheitherasmallcoreinfarctornocoreinfarct.9However,theinfarctsizethresholdforfutilityremainsunknown. ResultsfromtheHERMES(HighlyEffectiveReperfusionEvaluatedinMultipleEndovascularStroke)collaborationsuggestedpotentialbenefitsassociatedwithMTforpatientswithalowbaselineASPECTS,buttheresultswerelimitedbythesmallnumberofpatientswithlowASPECTS.4,8OtherobservationalstudieshavesuggestedpotentialbenefitsassociatedwithMTinthisgroup.10-14Similarly,thesestudieswerelimitedbythesmallsamplesizeandthelimitednumberofpatientstreatedintheextendedMTwindow(6-24hoursfromsymptomonsettogroinpuncture).Inthisstudy,wesoughttoinvestigatethesafetyandeffectivenessofMTinareal-worldcohortofpatientswithlargevesselocclusionandlargecoreinfarctintheearlythrombectomywindow(<6hoursfromsymptomonsettogroinpuncture)andanextendedthrombectomywindow.WecomparedtheoutcomesofMTforpatientswithalowvshighASPECTSusingacutoffof5orlessforalowASPECTSgiventhatthiscutoffwasusedinmostoftheMTclinicaltrials,includingESCAPE(EndovascularTreatmentforSmallCoreandAnteriorCirculationProximalOcclusionWithEmphasisonMinimizingCTtoRecanalizationTimes)15andDEFUSE3(EndovascularTherapyFollowingImagingEvaluationforIschemicStroke).5Then,weassessedtheMToutcomesofpatientswithalowASPECTSbasedonreperfusionstatusandtreatmentintheearlyvsextendedwindow,hypothesizingthatbothofthesefactorsmodifytheoutcomeassociatedwithMT. Methods StudyDesign Inthisretrospectivecohortstudy,wereviewedtheprospectivelymaintaineddatabasesof28strokecentersintheStrokeThrombectomyandAneurysmRegistry.Weincludedpatientswithacutestrokepresentingwithanocclusionintheinternalcarotidartery(ICA)orM1segmentofthemiddlecerebralarterywhoreceivedMTwithin24hoursofwitnessedsymptomonsetbetweenJanuary1,2016,andDecember31,2020.AllpatientswithanICAorM1occlusionunderwentMTregardlessoftheirperfusionstatus.AfterMT,patientswereadmittedtotheneurologicintensivecareunitineachoftheincludedcenters.Follow-upheadimageswereobtained24hoursafterMTtoassessthepresenceofhemorrhagictransformationandcerebraledema.Thestudywasapprovedbytheinstitutionalreviewboardateachoftheincludedcenters(MedicalUniversityofSouthCarolina;EmoryUniversitySchoolofMedicine;ThomasJeffersonUniversityHospitals;UniversityofMiamiHealthSystem;WakeForestSchoolofMedicine;UniversityofTennesseeHealthScienceCenter;UniversityofIowaHospitalsandClinics;UniversityMedicalCenterGöttingen;WestVirginiaSchoolofMedicine;UniversityofTexasHealthScienceCenteratSanAntonio;UniversityofBasel;MountSinaiHealthSystem;UniversityofArizona;UniversityofWashington;UniversityofFlorida;WashingtonUniversityinStLouis;EndovascularNeurologicalCenter,Montevideo,Uruguay;ChonnamNationalUniversityHospital;HospitalJuanFernandez;HyogoCollegeofMedicine;YaleSchoolofMedicine;UniversityofTexasMedicalBranch;AlleghenyHealthNetwork;CentreHospitalierRégionalUniversitairedeNancy;CentreHospitalierRégionalUniversitairedeNancy;HospitalSãoJoséCentroHospitalar;BonSecoursMercyHealthStVincentMedicalCenter;andTexasStrokeInstitute),andtheneedforinformedconsentwaswaivedgivenitsminimalriskdesign.ThisstudyfollowedtheStrengtheningtheReportingofObservationalStudiesinEpidemiology(STROBE)reportingguideline. DataCollectionandClinicalOutcome Collecteddataincludedbaselinedemographiccharacteristics,locationofocclusion,baselinecoreinfarctasdeterminedbytheASPECTS,timefromsymptomonsettogroinpuncture,MTtechnique,proceduretime,thrombectomypasses,devicesused,rescuetherapyused,complications,andfinalmodifiedThrombolysisinCerebralIschemiascore.PatientswithanASPECTSof2to5weredividedintoearlywindowandextendedwindowgroups.Baselineimaging,recanalizationrates,andpostproceduralimagingwerereviewedbylocalinvestigatorsateachparticipatingsite.SuccessfulrecanalizationwasdefinedasamodifiedThrombolysisinCerebralIschemiascoreof2Bormore.The90-daymodifiedRankinScale(mRS)scorewasusedastheprimaryoutcomemeasureandwasrecordedduringafollow-upvisitortelephoneencounteratamean(SD)of90(14)daysafterstrokebyastrokeneurologistorregisterednurse.16FavorableoutcomewasdefinedasanmRSscoreof0to2at90days.Symptomaticintracranialhemorrhagewasdefinedaspostproceduralhemorrhagewithanassociateddecreaseof4pointsormoreintheNationalInstitutesofHealthStrokeScale(NIHSS)score. StatisticalAnalysis Weuseddescriptivestatisticstoreportpatients’demographicandclinicalcharacteristics,usingmedian(IQR)valuesforcontinuousvariablesandpercentagesforcategoricalvariables.Thecharacteristicsofthe2groupswerecomparedusingtheWilcoxonranksum(Mann-Whitney)testandtheχ2testasappropriate.Weusedamultivariablelogisticregressionmodeltoassessthefactorsassociatedwith90-dayoutcomesforallpatientsundergoingMTwhopresentedwithICAorM1occlusion,andinteractiontermsbetweenanASPECTSof2to5andreceiptofMTintheextendedwindowwereused.Variablesincludedintheregressionmodelincludeage,locationofocclusion,admissionNIHSSscore,intravenousthrombolysis,successfulrecanalization,anASPECTSof2to5,andtreatmentintheextendedwindow.Finally,toassesswhethertheassociationbetweenanASPECTSof2to5andafavorableoutcomeismodifiedbythecenterinwhichthethrombectomywasperformed,weusedtheCochran-Mantel-Haenszeltest.AllPvalueswerefrom2-sidedtests,andresultsweredeemedstatisticallysignificantatP