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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Medical Management vs Mechanical Thrombectomy for Mild Strokes: An International Multicenter Study and Systematic
Nitin Goyal1,2, Georgios Tsivgoulis1,3, Konark Malhotra4
1Department of Neurology, University of Tennessee Health Science Center, Memphis.
Importance:
The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain.
Objective:
To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM).
Data Sources:
We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017.
Study Selection:
We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM.
Main Outcomes And Measures:
Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH).
Results:
We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P = .002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P = .02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P = .03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P = .002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P = .32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes.
Conclusions And Relevance:
Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial.
Insights
Mechanical thrombectomy (MT) and best medical management (bMM) showed similar outcomes for mild stroke due to large-vessel occlusion. Further randomized trials are needed to determine the optimal treatment for these patients.
Area of Science:
- Neurology
- Interventional Cardiology
- Vascular Surgery
Background:
- The efficacy of mechanical thrombectomy (MT) for stroke patients with mild deficits and large-vessel occlusion (LVO) is not well-established.
- Mild-deficit LVO (mELVO) represents a specific subgroup where treatment benefits require further investigation.
Purpose of the Study:
- To compare outcomes in patients with mELVO treated with MT versus best medical management (bMM).
- To evaluate the efficacy and safety of MT compared to bMM in this patient population.
Main Methods:
- Retrospective analysis of 251 patients with mELVO from 16 centers (2013-2017).
- Meta-analysis of 4 studies including 843 patients comparing MT and bMM for mELVO.
- Outcomes assessed included functional independence, favorable functional outcome, mortality, and intracranial hemorrhage (ICH).
Main Results:
- No significant differences in 3-month functional independence or favorable functional outcome between MT and bMM groups.
- Asymptomatic intracranial hemorrhage (ICH) rates were higher with MT (17.5%) compared to bMM (4.6%).
- Meta-analysis showed a trend towards higher symptomatic ICH with MT in unadjusted analyses, which was not significant after adjustment.
Conclusions:
- Current evidence suggests similar functional outcomes between MT and bMM for mELVO.
- Mechanical thrombectomy was associated with a higher rate of asymptomatic intracranial hemorrhage.
- Randomized clinical trials are necessary to definitively resolve clinical equipoise regarding MT for mELVO.
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