Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

Dobrocky, Tomas; Piechowiak, Eike Immo; Volbers, Bastian; Slavova, Nedelina; Kaesmacher, Johannes; Meinel, Thomas; Arnold, Marcel; Fischer, Urs; Jung, Simon; Gralla, Jan; Mordasini, Pasquale; Heldner, Mirjam R

doi:10.1161/strokeaha.120.031672

Cited by 29 publications

(28 citation statements)

References 27 publications

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“…Mean age, percentage of men or women, comorbidity (eg, atrial fibrillation), and median NIHSS score were not available because almost all of the included studies were not designed to explore the effect of EVT on specific vessel occlusion sites and we only retrieved the subset of data from these studies for the purpose of this meta-analysis. Only one study provided the percentage of patients who were treated after 2015 and this study showed that 111 out of 169 patients (65.7%) were treated after 2015, and mRS 0–1 at 3 months was not significantly different between the EVT versus IVT groups in mild ischemic stroke due to distal M2 occlusions 24…”

Section: Resultsmentioning

confidence: 82%

“…Pooled results showed that EVT compared with BMM was not associated with a significantly higher rate of symptomatic ICH in proximal ICA or M1 occlusions (5.1% vs 3.1%; OR 1.71, 95% CI 0.61 to 4.81),10 12 but was associated with a higher rate of symptomatic ICH in distal M2 occlusions (6.8% vs 2.3%; OR 3.44, 95% CI 1.42 to 8.32),10 12 24 and the effect of EVT in the proximal ICA or M1 versus distal M2 occlusions was not significantly different (P for interaction=0.31, I 2 =18%) (online supplemental eFigure 2).…”

Section: Resultsmentioning

confidence: 95%

“…Of the 29 studies retrieved for detailed assessment, two were excluded due to no comparable group in two studies, some patients having NIHSS scores >5 at baseline in five studies, or not reporting number of patients with freedom of disability or functional independence at 90 days in proximal ICA or M1 versus distal M2 occlusions separately in 16 studies (figure 1). Our final analysis included six studies,10 12 22–25 comprising 653 patients with proximal ICA or M1 occlusions and 666 patients with distal M2 occlusions, respectively, and NIHSS scores ≤5. Among patients with proximal ICA or M1 occlusions, 360 patients received EVT and 293 patients received BMM.…”

Section: Resultsmentioning

confidence: 99%

“…For AIS patients with NIHSS scores ≤5, pooled results from the fixed-effect model showed that EVT compared with BMM was associated with a non-significantly higher rate of functional independence in patients with proximal ICA or M1 occlusions (75.8% vs 75.2%; OR 1.23, 95% CI 0.83 to 1.84),10 12 22 23 but was associated with a non-significantly lower rate of functional independence in patients with distal M2 occlusions (78.3% vs 84.1%; OR 0.69, 95% CI 0.45 to 1.05),10 12 23 24 and the effect of EVT in the proximal ICA or M1 versus distal M2 occlusions was borderline different (P for interaction=0.05, I 2 =74%) (figure 3).…”

Section: Resultsmentioning

confidence: 99%

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Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

Lin

Saver

Ovbiagele

et al. 2022

J NeuroIntervent Surg

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ObjectiveTo conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions.MethodsWe searched PubMed, Embase, the Cochrane Library, and clinicaltrials.gov from January 2000 to September 2021 to identify studies comparing EVT versus best medical management (BMM) in AIS with National Institutes of Health Stroke Scale (NIHSS) scores ≤5 due to proximal internal carotid artery (ICA) or M1 versus distal M2 occlusions. We included studies that reported the number of patients with proximal or distal occlusions separately and reported the number of patients with freedom of disability (modified Rankin Scale (mRS) score 0–1) or functional independence (mRS score 0–2) at 90 days in proximal or M2 occlusions, respectively. OR with 95% CI was used.ResultsWe identified six studies with 653 proximal ICA and M1 occlusion patients and 666 distal M2 occlusion patients. Pooled results showed EVT versus BMM was associated with a higher rate of being disability-free in patients with proximal occlusions (OR 1.58, 95% CI 1.09 to 2.30), but was associated with a lower rate of being disability-free in patients with M2 occlusions (OR 0.70, 95% CI 0.49 to 0.99). Effect of EVT in proximal versus distal occlusions was substantially different (P for interaction=0.002). A similar pattern was seen for functional independence (P for interaction=0.05).ConclusionsFor patients with mild AIS, observational data suggest that EVT may be beneficial for proximal ICA or M1 but not for distal M2 occlusions. Randomized trials are needed to confirm these findings.PROSPERO registration numberCRD42021281034.

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Section: Resultsmentioning

confidence: 82%

Section: Resultsmentioning

confidence: 95%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 2 more Smart Citations

Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

Lin

Saver

Ovbiagele

et al. 2022

J NeuroIntervent Surg

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“…Other results suggested that intravenous thrombolysis might also be associated with deterioration due to thrombus fragmentation in some patients with ICA occlusion (22). The efficacy of bridging thrombolysis in those patients also remains to be elucidated (23). Those results underline the necessity to select the right patient for the right treatment.…”

Section: Discussionmentioning

confidence: 98%

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

et al. 2021

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Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients.Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor).Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p < 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90.Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.

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Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient‐Level Analysis from the EXTEND‐IA Trials, INSPIRE, and SELECT Studies

Sarraj

Bivard

Hassan

et al. 2022

Annals of Neurology

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Objective The objective of this study was to evaluate functional and safety outcomes of endovascular thrombectomy (EVT) versus medical management (MM) in patients with M2 occlusion and examine their association with perfusion imaging mismatch and stroke severity. Methods In a pooled, patient‐level analysis of 3 randomized controlled trials (EXTEND‐IA, EXTEND‐and IA‐TNK parts 1 and 2) and 2 prospective nonrandomized studies (INSPIRE and SELECT), we evaluated EVT association with 90‐day functional independence (modified Rankin Scale [mRS] = 0–2) in isolated M2 occlusions as compared to medical management overall and in subgroups by mismatch profile status and stroke severity. Results We included 517 patients (EVT = 195 and MM = 322), baseline median (interquartile range [IQR]) National Institutes of Health Stroke Scale (NIHSS) was 13 (8–19) in EVT versus 10 (6–15) in MM, p < 0.001. Pretreatment ischemic core did not differ (EVT = 10 [0–24] ml vs MM = 9 [3–21] ml, p = 0.59). Compared to MM, EVT was more frequently associated with functional independence (68.3 vs 61.6%, adjusted odds ratio [aOR] = 2.42, 95% confidence interval [CI] = 1.25–4.67, p = 0.008, inverse probability of treatment weights [IPTW]‐OR = 1.75, 95% CI = 1.00–3.75, p = 0.05) with a shift toward better mRS outcomes (adjusted cOR = 2.02, 95% CI:1.23–3.29, p = 0.005), and lower mortality (5 vs 10%, aOR = 0.32, 95% CI = 0.12–0.87, p = 0.025). EVT was associated with higher functional independence in patients with a perfusion mismatch profile (EVT = 70.7% vs MM = 61.3%, aOR = 2.29, 95% CI = 1.09–4.79, p = 0.029, IPTW‐OR = 2.02, 1.08–3.78, p = 0.029), whereas no difference was found in those without mismatch (EVT = 43.8% vs MM = 62.7%, p = 0.17, IPTW‐OR: 0.71, 95% CI = 0.18–2.78, p = 0.62). Functional independence was more frequent with EVT in patients with moderate or severe strokes, as defined by baseline NIHSS above any thresholds from 6 to 10, whereas there was no difference between groups with milder strokes below these thresholds. Interpretation In patients with M2 occlusion, EVT was associated with improved clinical outcomes when compared to MM. This association was primarily observed in patients with a mismatch profile and those with higher stroke severity. ANN NEUROL 2022;91:629–639

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Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

Cited by 29 publications

References 27 publications

Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

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

Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient‐Level Analysis from the EXTEND‐IA Trials, INSPIRE, and SELECT Studies

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