Endovascular therapy has added value in patients with acute large vessel occlusion

Endovascular therapy (EVT) in addition to medical therapy appeared to improve outcomes in patients with acute large vessel occlusion (LVO) with large ischaemic core following a stroke, according to results of the RESCUE-Japan LIMIT* trial.

“EVT increased independent patients by 2.43 times than medical therapy alone in acute LVO patients with large ischaemic regions,” presented lead author Professor Shinichi Yoshimura from the Hyogo College of Medicine in Nishinomiya, Japan, at ISC 2022.

A total of 203 adults (average age 76 years, 44 percent female) with acute LVO and large ischaemic core (ASPECTS 3–5) with an NIHSS** score ≥6 (median 22) and pre-mRS** 0–1 were recruited from 45 hospitals throughout Japan. They were randomized 1:1 to receive standard medical therapy with or without EVT performed within 1 hour of imaging (thrombectomy [stent-retriever, aspiration]), percutaneous transluminal angioplasty, stenting).

At 90 days, a greater proportion of patients who received EVT plus medical therapy achieved mRS 0–3 (ability to walk without assistance and with no residual disability) compared with those who only received medical therapy (31.0 percent vs 12.8 percent; relative risk [RR], 2.43, 95 percent confidence interval [CI], 1.35–4.37; p=0.002). [ISC 2022, abstract LB1]

Functional independence (mRS of 0–2; ability to carry out all pre-stroke activities or with slight disability that did not require daily assistance) at 90 days was also improved among patients in the EVT plus medical therapy vs medical therapy-only group (14.0 percent vs 6.9 percent; RR, 2.04, 95 percent CI, 0.86–4.84).

NIHSS score improvement of ≥8 points within 48 hours was observed in more EVT plus medical therapy than medical therapy recipients (31.0 percent vs 8.8 percent; odds ratio, 3.51, 95 percent CI, 1.76–7.00).

There was a significant increase in the risk of intracerebral haemorrhage (ICH) within 48 hours in patients who received EVT plus medical therapy vs medical therapy only (58.0 percent vs 31.4 percent; RR, 1.85, 95 percent CI, 1.33–2.58; p<0.001), though symptomatic ICH within 48 hours did not significantly differ between groups (9.0 percent vs 4.9 percent; RR, 1.84; p=0.25).

The risk of death within 90 days was also comparable between those who received EVT plus medical therapy vs medical therapy only (18.0 percent vs 23.5 percent; RR, 0.77; p=0.33), as was the risk of decompressive craniectomy within 7 days (10.0 percent vs 13.7 percent; RR, 0.73; p=0.41). The risk of recurrent ischaemic stroke within 90 days was low and comparable between groups (5.0 percent vs 6.9 percent; RR, 0.73; p=0.58). 

Serious adverse events (AEs) occurred in more EVT plus medical therapy than medical therapy-only recipients (33.6 percent vs 18.6 percent), the most common being pneumonia (13.9 percent vs 11.8 percent), liver injury (9.9 percent vs 5.9 percent), and cardiovascular events (9.9 percent vs 2.9 percent). Among the patients who received EVT, 8.9 percent experienced procedural complications.

The authors cautioned that the results may not necessarily apply to non-Japanese populations and acknowledged the possibility of incorrect ASPECT assessment in emergency settings in this study. The estimation of brain regions affected may also differ in countries where diagnosis is predominantly via CT scans rather than MRI which was used in the present study.

“Our findings confirm that anyone who suffers from stroke should be transferred to a medical facility capable of EVT as soon as possible,” said senior author Professor Takeshi Morimoto, also from the Hyogo College of Medicine.

“The benefit of EVT is not limited by the severity or region of a stroke. These patients may have the chance to more fully recover from stroke and go back to their previous lives and activity levels,” Morimoto added.