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Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke

. 2020 Dec 15 ; 95 (24) : e3364-e3372. [epub] 20200928

Language English Country United States Media print-electronic

Document type Comparative Study, Journal Article, Multicenter Study, Observational Study

Links

PubMed 32989100
PubMed Central PMC7836655
DOI 10.1212/wnl.0000000000010955
PII: WNL.0000000000010955
Knihovny.cz E-resources

OBJECTIVE: To undertake an effectiveness and safety analysis of EVT in patients with LVO and NIH Stroke Scale (NIHSS) score ≤6 using datasets of multicenter and multinational nature. METHODS: We 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 modified Rankin Scale (mRS) score 0-1 at 90 days. Secondary outcomes included neurologic deterioration at 24 hours (change in NIHSS of ≥2 points), mRS 0-2 at 90 days, and 90-day all-cause mortality. We used propensity score matching to adjust for nonrandomized treatment allocation. RESULTS: Among 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 IV 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% confidence interval [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. CONCLUSIONS: EVT for LVO in patients with low NIHSS score 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. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with acute anterior circulation ischemic strokes and LVO with NIHSS < 6, EVT and medical management result in similar outcomes at 90 days.

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Heldner MR, Zubler C, Mattle HP, et al. . National Institutes of Health Stroke Scale score and vessel occlusion in 2152 patients with acute ischemic stroke. Stroke 2013;44:1153–1157. PubMed

Maas MB, Furie KL, Lev MH, et al. . National Institutes of Health Stroke Scale score is poorly predictive of proximal occlusion in acute cerebral ischemia. Stroke 2009;40:2988–2993. PubMed PMC

Powers WJ, Rabinstein AA, Ackerson T, et al. . 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018;49:e46–e110. PubMed

Goyal M, Menon BK, van Zwam WH, et al. . Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723–1731. PubMed

Kim JT, Park MS, Chang J, Lee JS, Choi KH, Cho KH. Proximal arterial occlusion in acute ischemic stroke with low NIHSS scores should not be considered as mild stroke. PLoS One 2013;8:e70996. PubMed PMC

Rajajee V, Kidwell C, Starkman S, et al. . Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology 2006;67:980–984. PubMed

Coutts SB, Modi J, Patel SK, Demchuk AM, Goyal M, Hill MD. CT/CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective catch study. Stroke 2012;43:1013–1017. PubMed

Asdaghi N, Yavagal DR, Wang K, et al. . Patterns and outcomes of endovascular therapy in mild stroke. Stroke 2019;50:2101–2107. PubMed PMC

Sarraj A, Hassan A, Savitz SI, et al. . Endovascular thrombectomy for mild strokes: how low should we go? Stroke 2018;49:2398–2405. PubMed PMC

Nagel S, Bouslama M, Krause LU, et al. . Mechanical thrombectomy in patients with milder strokes and large vessel occlusions. Stroke 2018;49:2391–2397. PubMed

Dargazanli C, Arquizan C, Gory B, et al. . Mechanical thrombectomy for minor and mild stroke patients harboring large vessel occlusion in the anterior circulation: a multicenter cohort study. Stroke 2017;48:3274–3281. PubMed

Haussen DC, Lima FO, Bouslama M, et al. . Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts. J Neurointerv Surg 2018;10:325–329. PubMed

Pfaff J, Herweh C, Pham M, et al. . Mechanical thrombectomy in patients with acute ischemic stroke and lower NIHSS scores: recanalization rates, periprocedural complications, and clinical outcome. AJNR Am J Neuroradiol 2016;37:2066–2071. PubMed PMC

Wolman DN, Marcellus DG, Lansberg MG, et al. . Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms. Int J Stroke 2020;15:324–331. PubMed

Shang X, Lin M, Zhang S, et al. . Clinical outcomes of endovascular treatment within 24 hours in patients with mild ischemic stroke and perfusion imaging selection. AJNR Am J Neuroradiology 2018;39:1083–1087. PubMed PMC

Berkhemer OA, van Zwam WH, Dippel DW. Stent-retriever thrombectomy for stroke. N Engl J Med 2015;373:1076. PubMed

Goyal M, Demchuk AM, Menon BK, et al. . Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019–1030. PubMed

Jovin TG, Chamorro A, Cobo E, et al. . Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296–2306. PubMed

Saver JL, Goyal M, Diener HC. Stent-retriever thrombectomy for stroke. N Engl J Med 2015;373:1077. PubMed

Campbell BC, Mitchell PJ, Kleinig TJ, et al. . Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009–1018. PubMed

Volny O, Bar M, Krajina A, et al. . A comprehensive nationwide evaluation of stroke centres in the Czech Republic performing mechanical thrombectomy in acute stroke in 2016. Ceska Slovenska Neurol Neurochir 2017;113:445–450.

Santos EMM, d'Esterre CD, Treurniet KM, et al. . Added value of multiphase CTA imaging for thrombus perviousness assessment. Neuroradiology 2018;60:71–79. PubMed PMC

Menon BK, Al-Ajlan FS, Najm M, et al. . Association of clinical, imaging, and thrombus characteristics with recanalization of visible intracranial occlusion in patients with acute ischemic stroke. JAMA 2018;320:1017–1026. PubMed PMC

Siegler JE, Boehme AK, Kumar AD, Gillette MA, Albright KC, Martin-Schild S. What change in the National Institutes of Health stroke scale should define neurologic deterioration in acute ischemic stroke? J Stroke Cerebrovasc Dis 2013;22:675–682. PubMed PMC

Smith EE, Fonarow GC, Reeves MJ, et al. . Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With the Guidelines–Stroke. Stroke 2011;42:3110–3115. PubMed

Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM. Why are stroke patients excluded from tPA therapy? An analysis of patient eligibility. Neurology 2001;56:1015–1020. PubMed

Nedeltchev K, Schwegler B, Haefeli T, et al. . Outcome of stroke with mild or rapidly improving symptoms. Stroke 2007;38:2531–2535. PubMed

Smith EE, Abdullah AR, Petkovska I, Rosenthal E, Koroshetz WJ, Schwamm LH. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke 2005;36:2497–2499. PubMed

Mishra SM, Dykeman J, Sajobi TT, et al. . Early reperfusion rates with iv tPA are determined by CTA clot characteristics. AJNR Am J Neuroradiol 2014;35:2265–2272. PubMed PMC

Volny O, Krajina A, Belaskova S, et al. . Mechanical thrombectomy performs similarly in real world practice: a 2016 nationwide study from the Czech Republic. J Neurointerv Surg 2018;10:741–745. PubMed

Davis MJ, Menon BK, Baghirzada LB, et al. . Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology 2012;116:396–405. PubMed

Campbell BCV, van Zwam WH, Goyal M, et al. . Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018;17:47–53. PubMed

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