Stroke Etiology and Outcomes after Endovascular Thrombectomy: Results from the SITS Registry and a Meta-Analysis

Abstract

Background and Purpose The influence of stroke etiology on outcomes after endovascular thrombectomy (EVT) is not well understood. We aimed to investigate whether stroke etiology subgrouped as large artery atherosclerosis (LAA) and cardiac embolism (CE) influences outcomes in large artery occlusion (LAO) treated by EVT.Methods We included EVT treated LAO stroke patients registered in the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register between January 1, 2014 and September 3, 2019. Primary outcome was successful reperfusion (modified Treatment in Cerebral Infarction 2b-3). Secondary outcomes were symptomatic intracranial hemorrhage (SICH), 3-month functional independence (modified Ranking Scale 0–2) and death. Multivariable logistic regression models were used for comparisons. In addition, a meta-analysis of aggregate data from the current literature was conducted (PROSPERO, ID 167447).Results Of 7,543 patients, 1,903 (25.2%) had LAA, 3,214 (42.6%) CE, and 2,426 (32.2%) unknown, other, or multiple etiologies. LAA patients were younger (66 vs. 74, P<0.001) and had lower National Institutes of Health Stroke Scale score at baseline (15 vs. 16, P<0.001) than CE patients. Multivariable analyses showed that LAA patients had lower odds of successful reperfusion (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.57 to 0.86) and functional independence (OR, 0.74; 95% CI, 0.63 to 0.85), higher risk of death (OR, 1.44; 95% CI, 1.21 to 1.71), but no difference in SICH (OR, 1.09; 95% CI, 0.71 to 1.66) compared to CE patients. The systematic review found 25 studies matching the criteria. The meta-analysis did not find any difference between etiologies. Conclusions From the SITS thrombectomy register, we observed a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to CE etiology, despite more favorable baseline characteristics. In contrast, the meta-analysis did not find any difference between etiologies with aggregate data.

Bridging intravenous thrombolysis in patients with atrial fibrillation

“…In our study, almost half (46%) of the patients undergoing MT had concomitant AF, similar to other studies ( 2 ), stressing that this is a very frequent clinical scenario. Obviously, patients with AF are likely to receive OAC, if AF was known before stroke.…”

“…Atrial fibrillation (AF) causes ~20% of all acute ischemic stroke (AIS) cases ( 1 ), and 40% of large-vessel occlusion patients with AIS who undergo mechanical thrombectomy (MT) have a clinical history of AF ( 2 ).…”

Intra-arterial tenecteplase is safe and may improve the first-pass recanalization for acute ischemic stroke with large-artery atherosclerosis: the BRETIS-TNK trial

“…We only enrolled AIS-LVO patients with LAA etiology in this study given the difficulty in achieving recanalization during EVT in AIS-LVO patients with LAA etiology ( 15 , 16 ). Results from the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register indicated a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to cardiac embolism etiology ( 34 ). Previous studies have found that intra-arterial thrombolysis can increase recanalization and improve clinical outcomes ( 35 ).…”

Endovascular thrombectomy versus standard medical treatment for stroke patients with acute basilar artery occlusion: a systematic review and meta-analysis

“…BAO patients with in situ atherosclerotic thrombosis had significantly worse clinical outcomes and lower successful recanalization rates compared with BAO patients who had embolism without artery steno-occlusion 34. Matusevicius et al studied 7543 patients who underwent EVT, and showed that stroke patients with large artery atherosclerosis had lower successful reperfusion rates and worse functional outcomes than stroke patients with cardioembolism 35. In addition, several studies have shown that the cerebellar infarct volume before EVT was also a predictor of clinical outcomes in BAO patients 36–38.…”