Large core stroke thrombectomy: paradigm shift or futile exercise?

Chen, M; Leslie‐Mazwi, Thabele M; Hirsch, Joshua A; Albuquerque, Felipe C

doi:10.1136/jnis-2023-020219

Cited by 16 publications

(6 citation statements)

References 15 publications

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“…With expanding indications for endovascular therapy in AIS, such as in patients with large core strokes, there are concerns whether at some point an intervention becomes a futile procedure. [9][10][11] At the same time, evidence from a prospective study where neurointerventionalists' ability to predict clinical outcome after thrombectomy was evaluated showed that physicians performed poorly in prognosticating patient 90-day outcomes. 12 In a study of 299 patients undergoing thrombectomy, Fargen et al showed that physician interventionalists correctly predicted the patient's 90-day mRS tertile (0-2, 3-4 or 5-6) in only 44% of patients.…”

Section: Discussionmentioning

confidence: 99%

Patients’ perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke

Thanki,

Pressman,

Jade

et al. 2024

Interv Neuroradiol

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Background The modified Rankin Scale (mRS) is a clinician-reported scale that measures the degree of disability in patients who suffered a stroke. Patients’ perception of a meaningful recovery from severe stroke, expected value of a stroke intervention, and the effect of disparities are largely unknown. Methods We conducted a survey of patients, their family members, and accompanying visitors to understand their personal preferences and expectations for acute strokes potentially eligible for acute endovascular intervention using a hypothetical scenario of a severe stroke in a standardized questionnaire. Results Of 164 survey respondents, 65 (39.6%) were the patient involved, 93 (56.7%) were a family member, and six (3.7%) were accompanied visitors (friends, other). Minimally acceptable disability after a stroke intervention was considered as mRS 2 by 42 respondents (25.6%), as mRS 3 by 79 (48.2%), and as mRS 4 by 43 (26.2%) respondents. Race was associated with different views on this question ( p < 0.001; Hispanic and Black patients being more likely to accept disability than Caucasian and Asian patients), while sex ( p = 0.333) and age ( p = 0.560) were not. Sixty-three respondents (38.4%) viewed minimally acceptable probability of improvement with an intervention as over 50%, 57 (34.8%) as 10–50%, and 44 (26.8%) as less than 10%. Conclusions A wide range of acceptable outcomes were reported regardless of gender or age. However, race was associated with different acceptable outcome. This is an important finding to demonstrate because of the persistent racial and ethnic disparities in the utilization of endovascular therapy for acute stroke in the United States.

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Section: Discussionmentioning

confidence: 99%

Patients’ perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke

Thanki,

Pressman,

Jade

et al. 2024

Interv Neuroradiol

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“…Although rates of intracranial hemorrhage were higher, there was no evidence of a statistically significant increase in hemorrhagic complications. These data may lead to simplified thrombectomy selection criteria (ie, selection based solely on Alberta Stroke Program Early CT Score and evidence of an LVO) and subsequent higher rates of treatment for all patients with LVO 97 . All typical neurocritical care management considerations apply, although historical therapeutic nihilism regarding prognostication for these patients will need to evolve to reflect this contemporary therapeutic shift.…”

Section: Special Populations Of Patients With Stroke Due To Large Ves...mentioning

confidence: 99%

Neurocritical Care for Patients With Ischemic Stroke

Leslie-Mazwi

2024

CONTINUUM: Lifelong Learning in Neurology

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OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients’ prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.

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“…For a long time, there was a debate about whether thrombectomy in large core patients is futile or not. This paradigm shift is about to change due to the publication of these trials [96] . The expected benefits of performing thrombectomy in large core patients are mainly derived from reducing by nearly one-half the number of patients in the mRS 5 category, thereby reducing the associated stroke costs and caregiver burden.…”

Section: Large Corementioning

confidence: 99%

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

Radu,

Gascou,

Machi

et al. 2023

European Journal of Radiology Open

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Large core stroke thrombectomy: paradigm shift or futile exercise?

Cited by 16 publications

References 15 publications

Patients’ perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke

Patients’ perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke

Neurocritical Care for Patients With Ischemic Stroke

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

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