Clinical Outcomes of Endovascular Treatment within 24 Hours in Patients with Mild Ischemic Stroke and Perfusion Imaging Selection

Shang, Xianjin; Lin, Min; Zhang, S.; Li, Simin; Guo, Yue-Liang Leon; Wang, W.; Zhang, M.; Wan, Yue; Zhou, Zhiming; Zi, Wenjie; Liu, X.

doi:10.3174/ajnr.a5644

Cited by 13 publications

(7 citation statements)

References 27 publications

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“…Prior retrospective analyses of patients with mildly symptomatic AIS due to LVO have found similar rates of good clinical outcomes between patients following MM or ET with 64-75% of patients living independently at 90 days and symptomatic ICH in 6-17% of patients. [6][7][8][9][10]17 A multicenter analysis has suggested that ET may be performed safely in these patients and may lead to improved outcomes over medical therapy. 11 However, the study utilized heterogenous pretreatment imaging criteria and is confounded by the inclusion of different treatment arms between different centers.…”

Section: Discussionmentioning

confidence: 99%

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Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

Wolman

Marcellus

Lansberg

et al. 2019

International Journal of Stroke

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Background Acute ischemic stroke patients with a large-vessel occlusion but mild symptoms (NIHSS ≤ 6) pose a treatment dilemma between medical management and endovascular thrombectomy. Aims To evaluate the differences in clinical outcomes of endovascular thrombectomy-eligible patients with target-mismatch perfusion profiles who undergo either medical management or endovascular thrombectomy. Methods Forty-seven patients with acute ischemic stroke due to large-vessel occlusion, NIHSS ≤ 6, and a target-mismatch perfusion imaging profile were included. Patients underwent medical management or endovascular thrombectomy following treating neurointerventionalist and neurologist consensus. The primary outcome measure was NIHSS shift. Secondary outcome measures were symptomatic intracranial hemorrhage, in-hospital mortality, and 90-day mRS scores. The primary intention-to-treat and as-treated analyses were compared to determine the impact of crossover patient allocation on study outcome measures. Results Forty-seven patients were included. Thirty underwent medical management (64%) and 17 underwent endovascular thrombectomy (36%). Three medical management patients underwent endovascular thrombectomy due to early clinical deterioration. Presentation NIHSS ( P = 0.82), NIHSS shift ( P = 0.62), and 90-day functional independence (mRS 0–2; P = 0.25) were similar between groups. Endovascular thrombectomy patients demonstrated an increased overall rate of intracranial hemorrhage (35.3% vs. 10.0%; P = 0.04), but symptomatic intracranial hemorrhage was similar between groups ( P = 0.25). In-hospital mortality was similar between groups ( P = 0.46), though all two deaths in the medical management group occurred among crossover patients. Endovascular thrombectomy patients demonstrated a longer length of stay (7.6 ± 7.2 vs. 4.3 ± 3.9 days; P = 0.04) and a higher frequency of unfavorable discharge to a skilled-nursing facility ( P = 0.03) rather than home ( P = 0.05). Conclusions Endovascular thrombectomy may pose an unfavorable risk-benefit profile over medical management for endovascular thrombectomy-eligible acute ischemic stroke patients with mild symptoms, which warrants a randomized trial in this subpopulation.

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Section: Discussionmentioning

confidence: 99%

“…However, these prior studies suffer from heterogeneity in pre-treatment imaging, variability in triage with perfusion imaging, and comparisons between ET and medical management (MM) groups between different centers. [6][7][8][9][10][11][12]…”

Section: Introductionmentioning

confidence: 99%

Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

Wolman

Marcellus

Lansberg

et al. 2019

International Journal of Stroke

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“…All eligible subjects were divided into the MET group or the medical group, according to whether MET was performed. The MET group included the initial MET and rescue MET [13]. The local Ethics Committees of each center approved the use of patients’ data for this study, and written consents of the patients were waived due to its retrospective nature.…”

Section: Methodsmentioning

confidence: 99%

Efficacy and safety of endovascular thrombectomy in mild ischemic stroke: results from a retrospective study and meta-analysis of previous trials

Shang

Shi

et al. 2019

BMC Neurol

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Background Mechanical thrombectomy has been proven as a standard care for moderate to severe ischemic stroke with anterior large vessel occlusion (LVO); however, whether it is equally effective in mild ischemic stroke (MIS) is controversial. Methods In this retrospective study, a total of 177 Chinese patients presenting with MIS (NIHSS ≤8) and LVO between January 2014 and September 2017 from seven comprehensive stroke centers were identified. Odds of good outcome with endovascular thrombectomy versus medical treatment were obtained by logistic regression analysis and propensity-score matching method, and a meta-analysis pooled results from six studies ( n = 733). Results Good outcome (mRS: 0–1) was 58.2% (46/79) in the thrombectomy and 46.9% (46/98) in the medical group, which showed no statistical significance before adjustment ( P = 0.13; OR = 1.57, 95% CI: 0.86 to 2.86). The adjusted ORs of thrombectomy versus medical group were 3.23 (95% CI, 1.35 to 7.73; P = 0.008) by multivariable logistic analysis, 2.78 (1.12 to 6.89; P = 0.02) by propensity score matching analysis, and 3.20 (1.22 to 8.37; P = 0.01) by propensity score matching analysis with additional adjustments, respectively. Thrombectomy treatment did not result in excessive mortality or symptomatic intracranial hemorrhage after adjustments. The meta-analysis did not confirm the associations between good outcome and endovascular treatment. Conclusions The current study indicates that endovascular thrombectomy is associated with good functional outcome in MIS patients with LVO, and without additional risk of symptomatic intracranial hemorrhage and mortality. Although the meta-analysis failed to demonstrate its superiority compared to medical treatment, randomized clinical trials are needed. Electronic supplementary material The online version of this article (10.1186/s12883-019-1372-9) contains supplementary material, which is available to authorized users.

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“…For patients who are beyond the IVT treatment window, Shang et al demonstrated that EVT in patients with a low NIHSS score is feasible up to 24 hours following symptom onset; however, there was no functional improvement observed with EVT. 51 Robust collateral status has been correlated with reduced infarct expansion and favorable outcomes in LVO-AIS. 61 It is likely that low patients with LVO and a low NIHSS score with poor collateral status are more susceptible to END.…”

Section: Evt Patient Selectionmentioning

confidence: 99%

More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores

McCarthy

Tonetti

Stone

et al. 2020

J NeuroIntervent Surg

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While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78–97% and 0–10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.

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Clinical Outcomes of Endovascular Treatment within 24 Hours in Patients with Mild Ischemic Stroke and Perfusion Imaging Selection

Cited by 13 publications

References 27 publications

Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

Efficacy and safety of endovascular thrombectomy in mild ischemic stroke: results from a retrospective study and meta-analysis of previous trials

More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores

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