An analysis involving some 300 patients with anterior-circulation acute ischaemic strokes caused by tandem lesions has determined a number of factors that may be predictive of good clinical outcomes at three months following an endovascular mechanical thrombectomy procedure. Said factors include admission glycaemia; initiating dual antiplatelet therapy (DAPT) and statin therapy within 12 and 24 hours, respectively, post-procedure; and stent patency within the first 30 days.
Writing in CardioVascular and Interventional Radiology (CVIR), Daniel Šaňák (University Medical School and University Hospital Olomouc, Olomouc, Czech Republic) and colleagues note that these predictors of positive post-thrombectomy outcomes were present in their study “beside the generally known ones”.
“However,” the authors add, “it remains unclear whether early start of DAPT and statin therapy after [mechanical thrombectomy] could be affected by the preceding early neurological worsening followed with or without sICH [symptomatic intracranial haemorrhage] in some patients. Thus, a further large prospective study is needed.”
Initially averring that tandem lesions in the anterior circulation currently represent a “clinical challenge” in stroke thrombectomy treatment, Šaňák and colleagues attempted to assess potential predictors of good clinical outcomes in these patients via the multicentre, retrospective ASCENT study.
In ASCENT, a ‘good’ three-month outcome was defined as a score of 0–2 on the modified Rankin scale (mRS), while successful recanalisation was defined as a score of 2b–3 on the thrombolysis in cerebral infarction (TICI) scale. SICH was assessed using Safe implementation of thrombolysis in stroke-monitoring study (SITS-MOST) criteria. In addition, logistic regression analysis was used to evaluate possible predictors of mRS 0–2, with adjustment for potential confounders.
Ultimately, a total of 300 patients with a median National Institutes of Health stroke scale (NIHSS) score of 17—of whom 68.7% were male and who had a mean age of 67.3 years—were analysed in the study. Šaňák and colleagues note that recanalisation was achieved in 290 patients (96.7%), and 176 (58.7%) had an mRS score of 0–2.
Besides the more well-known predictors of post-thrombectomy outcomes, including age, NIHSS on admission, and sICH, the researchers identified that the following, less established factors were also present in ASCENT: lower admission glycaemia (p=0.005; odds ratio [OR], 0.884); stent patency within the first 30 days after thrombectomy (p=0.0003; OR, 0.219); DAPT started within 12 hours after thrombectomy (p<0.0001; OR, 5.006); and statin therapy started within 24 hours after thrombectomy (p<0.0001; OR, 5.558).
Prior to concluding, Šaňák and colleagues do acknowledge multiple limitations of their study, including its retrospective design and lack of central, blinded assessment of imaging findings. They also note that thrombectomy-related strategies—including carotid artery stenting (CAS), periprocedural antiplatelet regimen and postprocedural management—were not standardised or unified across all participating centres, and the possibility that these differences may have impacted their results cannot be excluded.
In addition, they state that the fact some patients did not receive DAPT due to early neurological worsening and/or presence of ICH on computed tomography (CT) imaging performed earlier than the first 12 hours after thrombectomy may limit the interpretation of their findings. However, no association between starting DAPT early and sICH occurrence was found in the study, they add.
