Thrombectomy for Acute Stroke Patients with Large Infarcts Associated with Better Outcomes/Lower Mortality vs Medical Care Only

According to study results published in The New England Journal of Medicine, endovascular thrombectomy plus medical care resulted in better functional outcomes and lower mortality versus medical care alone but led to a higher incidence of intracerebral hemorrhage in patients with acute stroke and a large infarct of unrestricted size. Since 2015, mechanical thrombectomy has been a standard of care for acute stroke patients with limited amounts of brain damage. Thrombectomy had not previously been studied in acute stroke patients with a large infarct of unrestricted size based on the perceived futility of thrombectomy in this population and the potential detrimental effects of reperfusion to large areas of irreversibly damaged brain, but this study suggests that thrombectomy could also benefit individuals with large ischemic core stroke. 

The multicenter, prospective, open-label, randomized, controlled LASTE clinical trial (NCT03811769) was conducted over a 3 year period at 33 certified high-volume stroke centers in France and Spain. Individuals with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (defined as an Alberta Stroke Program Early Computed Tomographic Score [ASPECTS] ≤5) detected within 6.5 hours of symptom onset were randomly assigned 1:1 to undergo endovascular thrombectomy and receive medical care (n=166) or receive medical care alone (n=167). The primary outcome was the modified Rankin Scale (mRS) score at 90 days, and the primary safety outcome was death from any cause at 90 days.

• The median mRS score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio [OR], 1.63; 95% CI, 1.29 to 2.06; P<.001). 
• Death from any cause at 90 days occurred in 36.1% of the thrombectomy group and 55.5% of the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84). 
• Symptomatic intracerebral hemorrhage was higher in the thrombectomy group (9.6% vs. 5.7%; adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68).