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Published on: November 26, 2013
Outcomes of Mechanical Thrombectomy in Patients With Acute Basilar Artery Occlusion With Mild to Moderate Symptoms
Ettore Nicolini1, Giovanni Pracucci1, Antonio Ciacciarelli1
1From the Department of Human Neuroscience (E.N., S.L., D.T.), Sapienza University of Rome; Stroke Unit (E.N., F.S.), Ospedale dei Castelli, Ariccia (RM); Department of NEUROFARBA (G.P.), Neuroscience Section, University of Florence; Stroke Unit (A.C., M.D.M.), Policlinico Umberto I, Sapienza University of Rome; Neurology and Stroke Unit (V.S., T.T.), S. Corona Hospital, Pietra Ligure, Italy; Interventional Neurovascular Unit (N. Limbucci), Careggi University Hospital; Careggi University Hospital (P.N.), Florence; AUSL Romagna Cesena (M.R.); Neurologia e Stroke Unit Ospedale Bufalini Cesena (M.L.); UO Neuroradiologia (M. Cosottini); Neurological Institute (G.O.), Azienda Ospedaliero Universitaria Pisana; Dipartimento di Neuroscienze (M.B.), Universitá di Torino; A.O. Cittá della Salute (P.C.), Torino; UO Neuroradiologia (S.V.); Neurologia-Stroke Unit (G. Bigliardi), Ospedale Civile di Baggiovara - AOU di Modena; UOC Neuroradiologia diagnostica e terapeutica AOU Senese (S.C.); UOC Stroke Unit AOU Senese (R.T.), Siena; Dipartimento di Biomedicina e Prevenzione - UOSD radiologia interventistica (V.D.R.); Department of Systems Medicine (M.D.), University of Rome Tor Vergata; IRCCS Istituto di Scienze Neurologiche di Bologna - UOC Neuroradiologia Ospedale Bellaria (L.S.); IRCCS Istituto di Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; UOC Neuroradiologia AOU "G. Martino" Messina (M.V.); UOSD Stroke Unit AOU "G. Martino"-Messina (P.L.L.S.); UO Neuroradiologia Ospedale Policlinico San Martino (L.C.); UO Neurologia Ospedale Policlinico San Martino (M.D.S.), Genova, Italy; Neurology Unit (I.C.), University Hospital Arcispedale S. Anna, Ferrara; Dipartimento di Scienze Biomediche (E.F.), Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi; Unità Complessa di Neuroradiologia (R.M.), Azienda Ospedaliero-Universitaria; Dipartimento di Medicina e Chirurgia (A.P.), Università degli Studi di Parma - Programma Stroke Care, Dipartimento di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria, Parma; UOSD Interventistica AOU Salerno (D.G.R.); UOC Neuroradiologia AOU Salerno (G.F.); Radiologia e Neuroradiologia diagnostica e interventistica (S.N.), IRCCS Policlinico San Matteo; UO Neurologia d'Urgenza e Stroke Unit (N. Loizzo), IRCCS Fondazione Mondino, Pavia; UO Neuroradiologia Dip Neuroscienze AZOU Ferrara (A.S.); UO Neurologia Dip Neuroscienze AZOU Ferrara (A.D.V.); Neuroradiology department ospedale di circolo- ASST Settelaghi Varese (R.A.); Stroke Unit - Azienda Ospedaliera Universitaria Integrata Verona (M. Cappellari); UO Neuroradiologia AOU Consorziale Policlinico Bari (D.S.Z.); UOC Neurologia e Stroke Unit "Puca" AOU Consorziale Policlinico Bari (M.P.); SC Neuroradiologia Diagnostica e Interventistica (L.A.), S. Corona Hospital, Pietra Ligure; UO Neuroradiologia interventistica (D.A.); Neurologia d'urgenza e Stroke Unit (S. Marcheselli), IRCCS Humanitas Research Hospital, Rozzano; UOC Neuroradiologia (M.P.G.); UOC Neurologia (G. Boero), Ospedale "SS. Annunziata", Taranto; IRCCS Neuromed (S. Mangiafico), Pozzilli (IS), Italy; Department of Clinical Neuroscience (N.A.), Karolinska Institutet, Stockholm, Sweden; Stroke Center EOC (C.W.C.), Neurocentre of Southern Switzerland; and Faculty of Biomedical Sciences (C.W.C.), Università della Svizzera Italiana, Lugano, Switzerland.
Background And Objectives:
The benefit of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) with basilar artery occlusion (BAO) and a baseline National Institute of Health Stroke Scale (NIHSS) score <10 is unclear because this subpopulation has been substantially excluded from large clinical trials. The aim of our study was to determine whether MT ± IV thrombolysis (IVT) improves functional outcomes compared with IVT alone in patients with BAO and a NIHSS score <10.
Methods:
We emulated a hypothetical trial including adult patients with BAO, a baseline NIHSS score <10, and prestroke modified Rankin scale (mRS) scores 0-2, comparing MT (±IVT) with IVT alone. We acquired data from patients receiving MT (±IVT) within 24 hours of onset from the Italian Registry of Endovascular Treatment in Acute Stroke and data from patients treated only with IVT within 9 hours of symptom onset from the SITS International Stroke Thrombolysis Register, from 2011 until 2021. We used inverse probability weighting (IPW) adjusted for prespecified covariates to weight each individual's contribution to the outcome. The primary outcome was 90-day mRS scores 0-2. Secondary outcomes included 90-day mRS scores 0-1, 90-day mRS scores 4-5, mortality at 90 days, in-hospital death, and symptomatic intracerebral hemorrhage.
Results:
Among the 764 patients recruited from the 2 databases (477 men [62.4%]; mean age [±SD] 67.88 [±13.9] years), 410 (53.7%) received MT±IVT and 354 (46.3%) only IVT. After applying IPW, our population was composed of 710 MT and 707 IVT patients. Of these, 454 MT-treated (63.9%) and 383 IVT-treated (54.2%) patients had a 90-day mRS score of 0-2 (adjusted odds ratio (aOR) 1.56 [95% CI 1.04-2.03]). MT was also associated with a higher rate of mRS scores 0-1 (aOR 2.01 [95% CI 1.37-2.95]) and a lower rate of in-hospital death (aOR 0.45 [95% CI 0.25-0.78]). Among the subgroups tested, MT had a larger effect on 90-day mRS scores 0-2 for patients with NIHSS scores 6-9 than for patients with a NIHSS score <6 (p for interaction 0.02).
Discussion:
In a large-scale target trial emulation on patients with stroke from BAO and a NIHSS score <10, MT was associated with better functional outcomes compared with IVT alone. Further research is needed to confirm the benefit of MT in patients with a NIHSS score <6.
Classification Of Evidence:
This study provides Class III evidence that MT ± intravenous thrombolysis is associated with better 90-day functional outcomes in patients with BAO and a NIHSS score < 10 compared with intravenous thrombolysis alone.
