The study “Endovascular Treatment of Patients With Acute Ischemic Stroke With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score” published in *J Am Heart Assoc* presents a retrospective analysis of endovascular thrombectomy (ET) in patients with acute ischemic stroke and tandem lesions. Despite its timely and relevant focus on a niche aspect of stroke treatment, the article suffers from several critical shortcomings that weaken its impact and utility in advancing clinical practice.
First, the methodology lacks rigor in several areas. While the authors employed inverse probability of treatment weighting (IPTW) to balance groups with different ASPECTS scores, this statistical approach is fraught with challenges. IPTW can only partially adjust for confounding variables and may still introduce biases that distort the relationship between treatment and outcomes. Additionally, the reliance on retrospective data from 16 centers raises concerns about the generalizability of the findings. The data, while extensive, are retrospective and not prospective, which significantly limits the strength of the conclusions.
Second, the outcomes presented, including symptomatic intracranial hemorrhage (sICH) and functional independence, are not analyzed in depth concerning potential confounders such as the timing of thrombectomy, variation in procedural expertise, and differences in patient management. Although the study finds that patients with low ASPECTS (0-5) have lower odds of functional recovery and higher odds of sICH, this oversimplification disregards the nuances that may impact outcomes in real-world clinical settings. The reported odds ratios (ORs) for functional recovery and sICH (0.48 and 3.78, respectively) do little to guide clinical decision-making, as they fail to explore the complexity of individual patient characteristics and treatment variables.
The suggestion that 30% of patients with low ASPECTS may still achieve functional independence should be viewed with caution. This result, while intriguing, is buried in a sea of statistical averages that gloss over the heterogeneity of stroke severity and treatment response. What does this functional independence mean in terms of quality of life for patients with low ASPECTS, and how does it compare to other treatment modalities or supportive care? These critical questions are left unaddressed.
Moreover, the paper glosses over the limitations of the study design, particularly the lack of standardization across the centers involved. Given the variability in treatment protocols and the experience of clinicians at each site, it’s difficult to draw definitive conclusions about the efficacy of ET in this cohort. The authors also fail to explore alternative explanations for the increased risk of sICH observed in the low ASPECTS group, such as the potential role of comorbidities or pre-existing vascular conditions.
The study’s conclusions also need more nuance. While it correctly notes that the low ASPECTS cohort faces worse outcomes, the implication that ET should be withheld from these patients due to “reduced odds of functional recovery” is problematic. Clinical decision-making in acute stroke care must consider the individual patient’s potential for recovery, comorbidities, and the risks associated with other interventions. A blanket recommendation against ET for low ASPECTS patients would be premature and overly simplistic, particularly in light of the 30% functional independence rate reported.
In summary, while the study addresses an important clinical question, its methodological flaws, lack of depth in analysis, and failure to consider confounding factors significantly diminish its value. The paper offers limited insight for clinicians faced with treating patients with low ASPECTS and tandem lesions, and its conclusions require careful interpretation before being applied in practice.