Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

Abstract

Background and aims: To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission ( p = 0.030). They were more frequently treated with stent retrievers ( p = 0.007), but the median number of stent retriever attempts was lower ( p = 0.016) and fewer had permanent stent placements ( p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift ( p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift ( p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

Stroke Aetiology and Collateral Status in Acute Ischemic Stroke Patients Receiving Reperfusion Therapy—A Meta-Analysis

“…Stroke aetiology may mediate collateral recruitment–potentially influencing response to time-critical reperfusion therapies in AIS [ 22 ]. This meta-analysis did not investigate this aspect.…”

“…This meta-analysis did not investigate this aspect. We postulate that in LAA patients, better collaterals develop over time in a proportion of patients resulting in high-grade stenosis [ 22 ]. Currently, data on whether stroke aetiology impacts reperfusion and outcomes after reperfusion therapy in AIS patients with large vessel occlusion in the anterior circulation, especially those treated with EVT or combined therapies (EVT ± IVT), are limited [ 23 , 24 ].…”

“…Currently, data on whether stroke aetiology impacts reperfusion and outcomes after reperfusion therapy in AIS patients with large vessel occlusion in the anterior circulation, especially those treated with EVT or combined therapies (EVT ± IVT), are limited [ 23 , 24 ]. However, previous studies have shown that CE patients have worse outcomes than LAA patients [ 22 , 25 , 26 ], presumably due to greater successful reperfusion rates [ 25 , 26 ]. However, other studies found no statistically significant difference in successful reperfusion rates between LAA and CE, despite higher rates of favourable 3-month functional outcomes, post-reperfusion, for LAA [ 22 , 23 , 24 ].…”

“…However, previous studies have shown that CE patients have worse outcomes than LAA patients [ 22 , 25 , 26 ], presumably due to greater successful reperfusion rates [ 25 , 26 ]. However, other studies found no statistically significant difference in successful reperfusion rates between LAA and CE, despite higher rates of favourable 3-month functional outcomes, post-reperfusion, for LAA [ 22 , 23 , 24 ]. Notably, in other studies, successful reperfusion is potentially more important for better outcomes and, specifically, more so in CE strokes than in the LAA [ 27 ].…”

“…Moreover, we also acknowledge that some of these subgroups could have overlapping aetiologies, e.g., in Hassler et al [ 12 ], 46 LAA subjects were only characterised by the presence of carotid artery stenosis but, among them, there were patients affected by atrial fibrillation, so they could be affected by cardioembolic strokes or, according to the TOAST classification, by strokes from an undetermined cause. Besides, given the varying pathogenesis of atherosclerotic occlusion based on the site of occlusion and heterogenous intervention protocols, it may be useful to compare LAA with CE for AIS with the same occlusion site [ 22 ].…”