What is the recommended management for an acute middle‑cerebral‑artery infarct with an Alberta Stroke Programme Early CT Score (ASPECTS) of zero?

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Management of Acute MCA Infarct with ASPECTS 0

For an acute middle cerebral artery infarct with ASPECTS 0, endovascular thrombectomy should generally not be performed, as this represents a complete large-core infarction with extremely poor prognosis and high hemorrhagic risk, though recent large-core trials have not specifically studied this extreme population. 1

Understanding ASPECTS 0

An ASPECTS of 0 indicates complete involvement of all 10 regions in the MCA territory—this represents essentially the entire MCA distribution with established infarction. 2 This is fundamentally different from the "large-core" populations studied in recent trials, which typically included patients with ASPECTS 3-5 or core volumes of 50-150 mL. 1

Evidence from Clinical Trials

Exclusion from Major Trials

  • All landmark endovascular thrombectomy trials establishing Level A evidence excluded patients with very low ASPECTS scores. 1, 3
  • The ESCAPE trial specifically required ASPECTS ≥6 for enrollment within 12 hours. 1
  • Even recent large-core trials (ANGEL-ASPECT, SELECT2, TENSION, LASTE) did not enroll patients with ASPECTS 0, typically setting lower limits at ASPECTS 2-3. 1

IV Alteplase Considerations

  • The 2018 AHA/ASA guidelines state that extent of hypoattenuation should not be used as a criterion to withhold IV alteplase in otherwise eligible patients, as meta-analyses showed no significant interaction between ASPECTS and alteplase benefit. 1
  • However, this recommendation was based on trials that excluded patients with >1/3 MCA territory involvement (ECASS I and II), and ASPECTS 0 represents far more extensive injury. 1

Clinical Reality and Prognosis

Hemorrhagic Risk

  • Patients with large ischemic cores face substantially increased risk of reperfusion hemorrhage, though the overall rate remains relatively low (4.4% in EVT vs 4.3% in controls across trials). 1
  • With ASPECTS 0, this risk is theoretically maximal, as there is no salvageable tissue and the entire territory is at risk for hemorrhagic transformation. 1

Functional Outcome

  • ASPECTS correlates linearly with functional outcome—lower scores predict worse outcomes regardless of treatment. 2, 4, 5
  • The original ASPECTS validation study showed that low ASPECTS values identify patients "unlikely to make an independent recovery despite thrombolytic treatment." 5
  • In the J-ACT trial, lower ASPECTS was significantly associated with symptomatic intracranial hemorrhage (OR 2.224,95% CI 1.227-4.032). 6

Practical Management Algorithm

Immediate Assessment

  1. Confirm ASPECTS 0 with expert review or automated software (RAPID ASPECTS shows better agreement than human readers, κ=0.9 vs 0.57). 7, 8
  2. Verify large vessel occlusion with CT angiography. 3
  3. Document exact time of symptom onset or last known well. 9

Treatment Decision Framework

Within 4.5 hours of onset:

  • Consider IV alteplase if no other contraindications exist, as guidelines do not exclude based on ASPECTS alone. 1
  • However, counsel family that prognosis is extremely poor regardless of treatment. 5
  • Do not pursue endovascular thrombectomy, as no trial evidence supports benefit in ASPECTS 0. 1, 3

Beyond 4.5 hours:

  • Do not administer IV alteplase (outside time window). 1
  • Do not pursue endovascular thrombectomy—patient does not meet DAWN or DEFUSE-3 criteria, which required some salvageable tissue. 3

Supportive Care Priorities

  • Avoid aggressive blood pressure lowering unless >220/120 mmHg, as this may worsen ischemia in any remaining penumbra. 9
  • Monitor for malignant cerebral edema, which is highly likely with complete MCA territory infarction. 9
  • Early neurosurgical consultation for potential decompressive hemicraniectomy in younger patients (<60 years) may be life-saving, though functional outcomes remain poor. 9

Critical Pitfalls to Avoid

  • Do not delay imaging interpretation hoping for better results—ASPECTS 0 is ASPECTS 0, and automated software may be more accurate than experienced readers in detecting early changes. 7, 8
  • Do not pursue thrombectomy based solely on "nothing to lose" reasoning—procedural complications can worsen an already catastrophic situation. 1
  • Do not withhold palliative care discussions—mortality and severe disability are nearly certain with complete MCA territory infarction. 5

Special Consideration: Age and Comorbidities

  • Even in patients ≥80 years where thrombectomy generally shows benefit (OR 3.68), this applies to patients with ASPECTS ≥6, not ASPECTS 0. 3
  • Pre-stroke functional status (mRS 0-1) is irrelevant when the entire MCA territory is infarcted—recovery to independence is not realistic. 3, 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Alberta Stroke Program Early CT Score (ASPECTS) Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Criteria for Thrombectomy in Acute Ischemic Stroke

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

9
Guideline

Initial Management of Suspected Stroke Before CT Scan

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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