Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke

Abstract

BackgroundEndovascular thrombectomy (EVT) is highly effective for acute ischemic stroke with large vessel occlusion (LVO) and moderate to severe neurologic deficits.ObjectiveTo undertake an effectiveness and safety analysis of EVT in patients with LVO and NIHSS ≤6 using datasets of multicentre and multinational nature.MethodsWe pooled patients with anterior circulation occlusion from 3 prospective international cohorts. Patients were eligible if presentation occurred within 12 hours from last known well and baseline NIHSS ≤6. Primary outcome was mRS 0–1 at 90 days. Secondary outcomes included neurologic deterioration at 24 hours (change in NIHSS of ≥2 points), mRS 0–2 at 90-day and 90-day all-cause mortality. We used propensity score matching to adjust for non-randomized treatment allocation.ResultsAmong 236 patients who fit inclusion criteria, 139 received EVT and 97 received medical management. Compared to medical management, the EVT group was younger (65 vs 72 years; p < 0.001), had more proximal occlusions (p < 0.001), and less frequently received concurrent intravenous thrombolysis (57.7% vs 71.2%; p = 0.04). After propensity score matching, clinical outcomes between the 2 groups were not significantly different. EVT patients had an 8.6% (95% CI: −8.8% to 26.1%) higher rate of excellent 90-day outcome, despite a 22.3% (95% CI: 3.0%–41.6%) higher risk of neurologic deterioration at 24 hours.ConclusionsEVT for LVO in patients with low NIHSS was associated with increased risk of neurologic deterioration at 24 hours. However, both EVT and medical management resulted in similar proportions of excellent clinical outcomes at 90 days.

Mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in the anterior circulation and low baseline National Institute of Health Stroke Scale score: a multicenter retrospective matched analysis

“…Dargazanli and coworkers have shown that patients with anterior circulation LVO and minor-to-mild symptoms (baseline NIHSS score < 8) have an excellent outcome after MT more often than those left on BMM, despite an increase rate of brain bleeding events [32]. On the other hand, a more recent multicenter study by Volny and coworkers, that included patients with occlusion of ICA and/or MCA (M1 and proximal M2 segments), has shown that MT was associated with a 8.6% higher chance of excellent outcome but with a 22.3% higher risk of neurological deterioration at 24 h and a 2.2% higher risk of death of any cause within 90 days [33].…”

Acute Stroke With Large Vessel Occlusion and Minor Clinical Deficits: Prognostic Factors and Therapeutic Implications

“…Here, the occlusion site may be of importance (7). Nevertheless, only limited evidence from retrospective data exists regarding the efficacy of MT (8,9), also in comparison to initial medical management with rescue intervention in case of secondary deterioration (10)(11)(12). However, mild stroke symptoms may not justify immediate MT in view of the procedure's invasiveness and potential serious adverse effects (13).…”

Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next?

“…Consequently, most of these patients may be denied a proven therapy due to low NIHSS scores [95,96]. Recently, retrospective studies have shown higher odds of improved outcomes for EVT in patients with LVO and NIHSS ≤ 5 [96][97][98]. Two multicenter clinical trials, ENDLOW (Endovascular Therapy for Low NIHSS Ischemic Strokes) trial (NCT04167527) in North America and MOSTE (Minor Stroke Therapy Evaluation) trial (NCT03796468) in Europe, are investigating the efficacy of EVT in patients with anterior circulation LVO and NIHSS ≤ 5 or 4, respectively.…”