Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke – Results from the SWISS registry

Abstract

Introduction: In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications. Materials and methods: In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0-1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel-Haenszel model. Results: Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients

Etiology of recurrent large vessel occlusions treated with repeated thrombectomy

“…9,[20][21][22] In line to a recent study, 9 based on the following three points, we believe a causative link between the intracranial lesions and stroke recurrence is possible: (i) in none of the patients with a contralateral recurrent stroke (patients 1-5), any intracranial lesion was detected. (ii) the time period between the first and second stroke was comparatively short in patients with a suspicious intracranial lesion (within seven days in patients 17,18,20,21,22) compared to all patients without such lesion with a range from 6 h to three years (patients 1-16) (iii) none of the suspicious intracranial findings was transient, but all were still detectable during second thrombectomy in each patient. This suspected -but not proved -causative relation between vessel lesions and stroke recurrence could explain why patients with a cardioembolic cause of stroke (such as patients 18, 20, 22) suffered from recurrent strokes in exactly the same location of the vessel, rather than a contralateral vessel as observed commonly in patients with a stroke of cardioembolic origin.…”

“…The first stroke was mostly (12 patients; 52%) classified as being of cardioembolic origin (TOAST 2; patients 1, 2, 4, 7, 9, 10, 15,16,18,19,20,22). In five patients, stroke was suspected to be caused by large atherosclerosis (TOAST 1; patients 11,14,17,21,23).…”

“…Among the five patients (patients 17,18,20,21,22) with any of the before-mentioned intracranial lesions In particular, treatment of patient no. 11, who presented with recurrent basilar artery thrombosis due to a local vasculopathy in the V2-segment of the right vertebral artery (VA) despite optimized secondary stroke prevention, is of note.…”

Contributing factors to quality of life after vertebral artery dissection: a prospective comparative study

“…The multivariate analysis of 126 patients with carotid and vertebral artery dissections in a retrospective study design showed that the variables stroke and arterial occlusion were independent factors associated with a poor outcome [37]. Traenka et al (2018) [38] reported more recently in their observational cohort study on patients with cervical, mainly carotid artery dissection, that numerically, but not statistically significant more patients with combined endovascular therapy (EVT)/intravenous thrombolysis (IVT) had excellent outcome and arterial recanalization than patients treated with EVT only. In our study, there was a trend in patients with good functional outcome (mRS score 0–2) to higher association of occlusion/subtotal occlusion with worse QOL, though this was statistically nonsignificant ( p < 0.05).…”

Neues beim Schlaganfall unter besonderer Berücksichtigung älterer Patienten

“…Ergänzend hilft die Anamnese: Für das PFO als erklärenden pathogenetischen Faktor [50] Oft ist in der Akutphase die Pathogenese noch ungeklärt, sodass viele durch eine Dissektion verursachte Schlaganfälle lysiert werden, ohne dass es zu einem schlechteren Ergebnis als bei Thrombolysen anderer Genese kommt [62,63]. Bei hämodynamisch relevanten, dissektiven Gefäßverschlüssen mit progredienten Defiziten oder Tandemverschlüssen mit dissektivem proximalem und distalem intrakraniellem Gefäßverschluss ist eine endovaskuläre Versorgung indiziert und effektiv [62].…”