Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients

Heldner, Mirjam Rachel; Jung, Simon; Zubler, Christoph; Mordasini, Pasquale; Weck, Anja; Mono, Marie‐Luise; Ozdoba, Christoph; El-Koussy, Marwan; Mattle, Heinrich; Schroth, Gerhard; Gralla, Jan; Arnold, Marcel; Fischer, Urs

doi:10.1136/jnnp-2014-308401

Cited by 92 publications

(73 citation statements)

References 27 publications

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“…The general approach to perform thrombolysis at our center has been described previously. [10][11][12] Intravenous thrombolysis in our institution was performed according to international and institutional guidelines. 13,14 Our bridging group received either full dose (0.9 mL/kg body weight) or two-thirds dose (0.6 mL/kg body weight) intravenous tPA within 4.5 hours after symptom onset.…”

Section: Methodsmentioning

confidence: 99%

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke

Broeg-Morvay

Mordasini

Bernasconi

et al. 2016

Stroke

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122

109

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Background and Purpose-Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear. Methods-We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2. Results-From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group. Conclusions-In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted. (Stroke.

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Section: Methodsmentioning

confidence: 99%

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke

Broeg-Morvay

Mordasini

Bernasconi

et al. 2016

Stroke

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122

109

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“…While historically thought to be a relatively benign condition, more recent data have shown that even these putatively minor strokes, if untreated, lead to higher rates of early neurologic decline, requiring rescue thrombectomy in up to 40% of patients, as well as lower rates of favorable clinical outcomes and independence, compared to patients receiving thrombolysis, ET, or both, with the greatest trend towards poor outcomes amongst untreated patients with an NIHSS score of 5-7 [5,8,15,17]. …”

Section: Discussionmentioning

confidence: 99%

“…Nearly one-third of patients are not treated with intravenous tPA due to mild or rapidly improving symptoms [3,4]. Previous reports have addressed the potential benefit of intravenous tPA and/or ET for low NIHSS score given the outcomes of untreated patients, with the greatest potential for benefit amongst those patients with lower symptom severity and imaging-proven LVOS; however, the data on treated cohorts are limited by small sample sizes and the inclusion of patients with lacunar disease [5,6,7,8,9,10,11]. Thus, we set out to evaluate the clinical and imaging outcomes of a cohort of endovascularly treated LVOS patients presenting with initial mild symptoms (NIHSS score ≤8).…”

Section: Introductionmentioning

confidence: 99%

Clinical and Imaging Outcomes of Endovascular Therapy in Patients with Acute Large Vessel Occlusion Stroke and Mild Clinical Symptoms

et al. 2017

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Background: The minimal stroke severity justifying endovascular intervention remains elusive. However, a significant proportion of patients presenting with large vessel occlusion stroke (LVOS) and mild symptoms go untreated and face poor outcomes. We aimed to evaluate the clinical outcomes of patients presenting with LVOS and low symptom scores (National Institutes of Health Stroke Scale [NIHSS] score ≤8) undergoing endovascular therapy (ET). Methods: We performed a retrospective analysis of a prospectively collected ET database between September 2010 and March 2016. Endovascularly treated patients with LVOS and a baseline NIHSS score ≤8 were included. Baseline patient characteristics, procedural details, and outcome parameters were collected. Efficacy outcomes were the rate of good outcome (90-day modified Rankin Scale score 0-2) and of successful reperfusion (modified Treatment in Cerebral Infarction [mTICI] score 2b-3). Safety was assessed by the rate of parenchymal hematoma (parenchymal hematoma type 1 [PH-1] and parenchymal hematoma type 2 [PH-2]) and 90-day mortality. Logistic regression was used to identify predictors of good clinical outcomes. Results: A total of 935 patients were considered; 72 patients with an NIHSS score ≤8 were included. Median [IQR] age was 61.5 years [56.2-73.0]; 39 patients (54%) were men. Mean (SD) baseline NIHSS score, computed tomography perfusion core volume, and ASPECTS were 6.3 (1.5), 7.5 mL (16.1), and 8.5 (1.3), respectively. Twenty-eight patients (39%) received intravenous tissue plasminogen activator. Occlusions locations were as follows: 29 (40%) proximal MCA-M1, 20 (28%) MCA-M2, 6 (8%) ICA terminus, and 9 (13%) vertebrobasilar. Tandem occlusion was documented in 7 patients (10%). Sixty-seven patients (93%) achieved successful reperfusion (mTICI score 2b-3); 52 (72%) had good 90-day outcomes. Mean final infarct volume was 32.2 ± 59.9 mL. Parenchymal hematoma occurred in 4 patients (6%). Ninety-day mortality was 10% (n = 7). Logistic regression showed that only successful reperfusion (OR 27.7, 95% CI 1.1-655.5, p = 0.04) was an independent predictor of good outcomes. Conclusion: Our findings demonstrate that ET is safe and feasible for LVOS patients presenting with mild clinical syndromes. Future controlled studies are warranted.

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“…7 Due to the fragile collateral circulation in patients with MIS and LVO, their clinical symptoms could worsen gradually in the short term, and they may finally have severe dis-ability, so timely endovascular recanalization remains critical. [8][9][10][11] However, further studies of high quality are needed to confirm the efficacy and safety of thrombectomy for these patients.…”

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confidence: 99%

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

Shang

Lin

Zhang

et al. 2018

AJNR Am J Neuroradiol

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Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients

Cited by 92 publications

References 27 publications

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke

Clinical and Imaging Outcomes of Endovascular Therapy in Patients with Acute Large Vessel Occlusion Stroke and Mild Clinical Symptoms

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

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