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Unsuccessful Recanalization versus Medical Management of Patients with Large Ischemic Core

Analysis of the ANGEL-ASPECT Randomized Trial

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Abstract

Purpose

The outcomes of patients with large ischemic core who fail to recanalize with endovascular therapy (EVT) compared to medical management (MM) are uncertain. The objective was to evaluate the clinical and safety outcomes of patients who underwent EVT in patients with large ischemic core and unsuccessful recanalization.

Methods

This was a post hoc analysis of the ANGEL-ASPECT randomized trial. Unsuccessful recanalization was defined as patients who underwent EVT with eTICI 0–2a. The primary endpoint was 90-day very poor outcome (mRS 5–6). Multivariable logistic regression was conducted controlling for ASPECTS, occlusion location, intravenous thrombolysis, and time to treatment.

Results

Of 455 patients 225 were treated with MM. Of 230 treated with EVT, 43 (19%) patients had unsuccessful recanalization. There was no difference in 90-day very poor outcomes (39.5% vs. 40%, aOR 0.93, 95% confidence interval, CI 0.47–1.85, p = 0.95), sICH (7.0% vs. 2.7%, aOR 2.81, 95% CI 0.6–13.29, p = 0.19), or mortality (30% vs. 20%, aOR 1.65, 95% CI 0.89–3.06, p = 0.11) between the unsuccessful EVT and MM groups, respectively. There were higher rates of ICH (55.8% vs. 17.3%, p < 0.001), infarct core volume growth (142.7 ml vs. 90.5 ml, β = 47.77, 95% CI 20.97–74.57 ml, p < 0.001), and decompressive craniectomy (18.6% vs. 3.6%, p < 0.001) in the unsuccessful EVT versus MM groups.

Conclusion

In a randomized trial of patients with large ischemic core undergoing EVT with unsuccessful recanalization, there was no difference in very poor outcomes, sICH or death versus medically managed patients. In the unsuccessful EVT group, there were higher rates of any ICH, volume of infarct core growth, and decompressive craniectomy.

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Funding

The ANGEL ASPECT randomized trial was supported by unrestricted grants from Covidien Healthcare International Trading (Shanghai), Johnson & Johnson MedTech, Genesis MedTech (Shanghai), and Shanghai HeartCare Medical Technology.

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Authors and Affiliations

  1. Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China

    Dapeng Sun, Yuesong Pan, Xu Tong, Xuan Sun, Ligang Song, Ning Ma, Feng Gao, Dapeng Mo, Zhongrong Miao & Xiaochuan Huo

  2. Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA

    Thanh N. Nguyen & Mohamad Abdalkader

  3. Neurology, SUNY Upstate Medical University Hospital, Syracuse, NY, USA

    Hesham E. Masoud

  4. Neurosurgery, Royal North Shore Hospital, Sydney, Australia

    Alice Ma

  5. China National Clinical Research Centre for Neurological Diseases, Beijing, China

    Yuesong Pan & Mengxing Wang

  6. Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China

    Gaoting Ma

  7. Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China

    Xiaochuan Huo

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  1. Dapeng Sun
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Correspondence to Zhongrong Miao or Xiaochuan Huo.

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Conflict of interest

T.N. Nguyen reports advisory board with Idorsia, Brainomix, Associate Editor of Stroke. D. Sun, Y. Pan, M. Wang, M. Abdalkader, H.E. Masoud, A. Ma, X. Tong, G. Ma, X. Sun, L. Song, N. Ma, F. Gao, D. Mo, Z. Miao, X. Huo and declare that they have no competing interests.

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62_2024_1384_MOESM1_ESM.docx

Table S1. Multivariable analysis comparing patients with unsuccessful recanalization and medical management, adjusted for age, baseline ASPECTS, occlusion site, intravenous thrombolysis, time from onset to randomization

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Sun, D., Nguyen, T.N., Pan, Y. et al. Unsuccessful Recanalization versus Medical Management of Patients with Large Ischemic Core. Clin Neuroradiol (2024). https://doi.org/10.1007/s00062-024-01384-5

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