Clot burden score and clinical outcomes in patients with a large infarct: a post hoc analysis of the ANGEL-ASPECT trial.

Abstract

Endovascular therapy (EVT) has proven to be beneficial in patients with acute large-vessel occlusion (LVO) and a large infarct. The authors aimed to investigate the outcomes of EVT across different thrombus burdens indicated by the clot burden score (CBS). This is a post hoc analysis of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial, which, between October 2, 2020, and May 18, 2022, enrolled patients with acute LVO within 24 hours of symptom onset who had an Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) of 3-5 or 0-2 and an infarct-core volume of 70-100 mL. Patients were divided into 2 groups according to the CBS: 0-6 versus 7-9. The primary outcome was the 90-day modified Rankin Scale score ordinal distribution. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality. This study included 429 patients. Among them, 354 (82.5%) patients had a CBS of 0-6, and 75 (17.5%) had a CBS of 7-9. Compared with medical management, EVT was associated with a significant shift toward a better functional outcome at 90 days in the CBS 0-6 subgroup (generalized OR 1.394, 95% CI 1.120-1.736, p = 0.003). However, no significant treatment effect of EVT was observed in the CBS 7-9 subgroup (common OR 1.155, 95% CI 0.517-2.580, p = 0.725). No interaction effect was found between the 2 CBS subgroups (p for interaction = 0.307). In patients with LVOs and large infarcts, EVT improves functional outcomes in those with a higher thrombus burden but not in those with a lower burden. The CBS has a potential role in selecting candidates for EVT.