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Khunte M, Wu X, Koo A, Payabvash S, Matouk C, Heit JJ, Wintermark M, Albers GW, Sanelli PC, Gandhi D, Malhotra A. Cost-effectiveness of thrombectomy in patients with minor stroke and large vessel occlusion: effect of thrombus location on cost-effectiveness and outcomes. J Neurointerv Surg 2023; 15:39-45. [PMID: 35022300 DOI: 10.1136/neurintsurg-2021-018375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the cost-effectiveness of endovascular thrombectomy (EVT) to treat large vessel occlusion (LVO) in patients with acute, minor stroke (National Institute of Health Stroke Scale (NIHSS) <6) and impact of occlusion site. METHODS A Markov decision-analytic model was constructed accounting for both costs and outcomes from a societal perspective. Two different management strategies were evaluated: EVT and medical management. Base case analysis was done for three different sites of occlusion: proximal M1, distal M1 and M2 occlusions. One-way, two-way and probabilistic sensitivity analyses were performed. RESULTS Base-case calculation showed EVT to be the dominant strategy in 65-year-old patients with proximal M1 occlusion and NIHSS <6, with lower cost (US$37 229 per patient) and higher effectiveness (1.47 quality-adjusted life years (QALYs)), equivalent to 537 days in perfect health or 603 days in modified Rankin score (mRS) 0-2 health state. EVT is the cost-effective strategy in 92.7% of iterations for patients with proximal M1 occlusion using a willingness-to-pay threshold of US$100 000/QALY. EVT was cost-effective if it had better outcomes in 2%-3% more patients than intravenous thrombolysis (IVT) in absolute numbers (base case difference -16%). EVT was cost-effective when the proportion of M2 occlusions was less than 37.1%. CONCLUSIONS EVT is cost-effective in patients with minor stroke and LVO in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with non-reperfusion. Our study emphasizes the need for caution in interpreting previous observational studies which concluded similar results in EVT versus medical management in patients with minor stroke due to a high proportion of patients with M2 occlusions in the two strategies.
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Affiliation(s)
- Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Andrew Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Gregory W Albers
- Department of Neurology and Neurosurgery, Stanford University, Stanford, California, USA
| | - Pina C Sanelli
- Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
| | - Dheeraj Gandhi
- Department of Interventional Neuroradiology, University of Maryland, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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2
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Fiehler J, Nawka MT, Meyer L. Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke. Curr Opin Neurol 2022; 35:18-23. [PMID: 34812746 DOI: 10.1097/wco.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. RECENT FINDINGS Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. SUMMARY The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.
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Affiliation(s)
- Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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A Comparative Evaluation of Standard and Balloon-Assisted Coiling of Intracranial Aneurysms Based on Neurophysiological Monitoring. J Clin Med 2022; 11:jcm11030677. [PMID: 35160124 PMCID: PMC8836763 DOI: 10.3390/jcm11030677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Intracranial aneurysms are commonly treated with balloon-assisted endovascular coiling because the balloon allows for the control und modulation of wide-necked aneurysms and the coil basket. However, this approach might be associated with a higher complication rate. This retrospective study compared the multimodal results between balloon-assisted coiling of aneurysms (group 1) and coiling without balloon assistance (group 2). MATERIALS AND METHODS We included 67 patients with unruptured intracranial aneurysms in this retrospective analysis; acutely ruptured aneurysms were excluded from the analysis. We divided these patients into two groups and evaluated them for symptomatic thromboembolic complications in the course of intracranial aneurysm treatment. All patients had an intrainterventional neurophysiological monitoring (IINM) and a pre- and postinterventional NIH Stoke Scale (NIHSS) survey and MR imaging. Multiple logistic regression was used to assess whether balloon-assisted coiling increased the rate of thromboembolic complications. Periprocedural aneurysm hemorrhage did not occur in any of the cases. RESULTS We detected no statistically significant difference in rates of neurophysiological disturbances (19.5% (group 1) versus 34.6% (group 2); p = 0.249). There was no association with age, gender, or aneurysm location. The occurrence of new diffusion-weighted defects was not statistically significantly different (19.5% (group 1) versus 35.0% (group 2); p = 0.166). The difference in NIHSS before and after the intervention showed also no statistical significance in both groups (p = 0.426). CONCLUSION The use of balloon-assisted coiling did not increase the rate of neurological disturbances during endovascular coiling. MR imaging and NIHSS survey also showed no increased risk of embolization from balloon-assisted aneurysm coiling. IINM is a central aspect of care during endovascular coiling as it can substantially decrease morbidity.
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4
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McDonough R, Cimflova P, Kashani N, Ospel JM, Kappelhof M, Singh N, Sehgal A, Sakai N, Fiehler J, Chen M, Goyal M. Patient-Relevant Deficits Dictate Endovascular Thrombectomy Decision-Making in Patients with Low NIHSS Scores with Medium-Vessel Occlusion Stroke. AJNR Am J Neuroradiol 2021; 42:1834-1838. [PMID: 34413064 DOI: 10.3174/ajnr.a7253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a paucity of evidence regarding the safety of endovascular treatment for patients with acute ischemic stroke due to primary medium-vessel occlusion. The aim of this study was to examine the willingness among stroke physicians to perform endovascular treatment in patients with mild-yet-disabling deficits due to medium-vessel occlusion. MATERIALS AND METHODS In an international cross-sectional survey consisting of 7 primary medium-vessel occlusion case scenarios, participants were asked whether the presence of personally disabling deficits would influence their decision-making for endovascular treatment despite the patients having low NIHSS scores (<6). Decision rates were calculated on the basis of physician characteristics. Univariable logistic regression clustered by respondent and scenario identity was performed. RESULTS Three hundred sixty-six participants from 44 countries provided 2562 answers to the 7 medium-vessel occlusion scenarios included in this study. In scenarios in which the deficit was relevant to the patient's profession, 56.9% of respondents opted to perform immediate endovascular treatment compared with 41.0% when no information regarding the patient's profession was provided (risk ratio = 1.39, P < .001). The largest effect sizes were seen for female participants (risk ratio = 1.68; 95% CI, 1.35-2.09), participants older than 60 years of age (risk ratio = 1.61; 95% CI, 1.23-2.10), those with more experience in neurointervention (risk ratio = 1.60; 95% CI, 1.24-2.06), and those who personally performed >100 endovascular treatments per year (risk ratio = 1.63; 95% CI, 1.22-2.17). CONCLUSIONS The presence of a patient-relevant deficit in low-NIHSS acute ischemic stroke due to medium-vessel occlusion is an important factor for endovascular treatment decision-making. This may have relevance for the conduct and interpretation of low-NIHSS endovascular treatment in randomized trials.
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Affiliation(s)
- R McDonough
- From the Department of Diagnostic and Interventional Neuroradiology (R.M., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - P Cimflova
- Department of Medical Imaging (P.C., M.G.), St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Clinical Neurosciences (P.C., N.S.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - N Kashani
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - M Kappelhof
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology and Nuclear Medicine (M.K.), University of Amsterdam, Amsterdam, the Netherlands
| | - N Singh
- Department of Clinical Neurosciences (P.C., N.S.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - A Sehgal
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - N Sakai
- Department of Neurosurgery (N.S.), Kobe City Medical Centre General Hospital, Kobe, Japan
| | - J Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (R.M., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Chen
- Department of Neurological Sciences (M.C.), Rush University Medical Center, Chicago, Illinois
| | - M Goyal
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
- Department of Medical Imaging (P.C., M.G.), St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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5
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Slawski D, Heit JJ. Treatment Challenges in Acute Minor Ischemic Stroke. Front Neurol 2021; 12:723637. [PMID: 34557152 PMCID: PMC8452987 DOI: 10.3389/fneur.2021.723637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/11/2021] [Indexed: 01/12/2023] Open
Abstract
Patients with acute ischemic stroke may present with minor neurologic deficits. Acute treatment decisions depend on the disability imposed by the symptoms along with radiographic features. The presence of disabling neurologic deficits warrants intravenous thrombolysis, but the indications for endovascular therapy are less defined. The degree of disability, presence of a large vessel occlusion with perfusion mismatch, and collateral circulation status may all be factors in selecting patients for endovascular treatment. Identification of patients who are at risk for neurologic deterioration is critical to preventing poor outcomes in this patient population.
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Affiliation(s)
- Diana Slawski
- Department of Neurology, Stanford Health Care, Stanford, CA, United States
| | - Jeremy J Heit
- Department of Neuroimaging and Neurointervention, Stanford Health Care, Stanford, CA, United States
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6
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Ospel JM, Menon BK, Goyal M. Questions on Predicting Early Neurological Deterioration in Patients With Minor Stroke and Large-Vessel Occlusion. JAMA Neurol 2021; 78:1020. [PMID: 34228060 DOI: 10.1001/jamaneurol.2021.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Johanna M Ospel
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Seaman Family Magnetic Resonance Research Centre, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
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7
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Haring J, Mako M, Haršány J, Krastev G, Hoferica M, Klepanec A. Aspiration Thrombectomy in Patients with Large Vessel Occlusion and Mild Stroke: A Single-Center Experience. Med Sci Monit 2021; 27:e930014. [PMID: 34016941 PMCID: PMC8147007 DOI: 10.12659/msm.930014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate outcomes of patients with mild stroke, defined by National Institutes of Health Stroke Scale (NIHSS) score <6, caused by large vessel occlusion treated with aspiration thrombectomy. MATERIAL AND METHODS Data from the endovascular stroke registry of our center were retrospectively analyzed. Anterior or posterior circulation strokes with NIHSS score <6 upon admission were analyzed. The assessment of a good clinical outcome (modified Rankin scale score 0-2) at day 90 was the primary endpoint. Symptomatic intracranial hemorrhage, defined in European Cooperative Acute Stroke Study grade III, and mortality at day 90 were the safety measures. A successful endovascular procedure was defined as a Thrombolysis in Cerebral Infarction (TICI) score of 2b or 3. RESULTS We included 27 patients treated with immediate mechanical thrombectomy, 19 (70.4%) in the anterior circulation and 8 (29.6%) in the posterior circulation. The mean age was 69.8±12.3 years and 40.7% were male. Thirteen patients (48.1%) received bridging intravenous thrombolysis before endovascular thrombectomy. Twenty-five patients (92.6%) underwent the direct aspiration first-pass technique "ADAPT" as the first choice of endovascular procedure. Successful recanalization was achieved in 25 patients (92.6%). Twenty-one patients (77.8%) had a good functional outcome at the 3-month follow-up, 1 (3.7%) symptomatic intracranial hemorrhage was observed, and 2 patients (7.4%) died. CONCLUSIONS Immediate aspiration thrombectomy may be a safe and feasible first-line treatment option in patients suffering from mild stroke due to large vessel occlusion in the anterior and posterior circulation.
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Affiliation(s)
- Jozef Haring
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia.,Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Miroslav Mako
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia.,Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Bratislava, Slovakia
| | - Ján Haršány
- Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia.,Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Georgi Krastev
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Matúš Hoferica
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Andrej Klepanec
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
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8
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Cimflova P, Kappelhof M, Singh N, Kashani N, Ospel JM, McDonough R, Demchuk AM, Menon BK, Sakai N, Chen M, Fiehler J, Goyal M. Factors influencing thrombectomy decision making for primary medium vessel occlusion stroke. J Neurointerv Surg 2021; 14:350-355. [PMID: 33947769 DOI: 10.1136/neurintsurg-2021-017472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND We aimed to explore the preference of stroke physicians to treat patients with primary medium vessel occlusion (MeVO) stroke with immediate endovascular treatment (EVT) in an international cross-sectional survey, as there is no clear guideline recommendation for EVT in these patients. METHODS In the survey MeVO-Finding Rationales and Objectifying New Targets for IntervEntional Revascularization in Stroke (MeVO-FRONTIERS), participants were shown four cases of primary MeVOs (six scenarios per case) and asked whether they would treat those patients with EVT. Multivariable logistic regression with clustering by respondent was performed to assess factors influencing the decision to treat. Dominance analysis was performed to assess the influence of factors within the scenarios on decision making. RESULTS Overall, 366 participants (56 women; 15%) from 44 countries provided 8784 answers to 24 scenarios. Most physicians (59.2%) would treat patients immediately with EVT. Younger patient age (incidence rate ratio (IRR) 1.24, 99% CI 1.19 to 1.30), higher National Institutes of Health Stroke Scale (NIHSS) score (IRR 1.69, 99% CI 1.57 to 1.82), and small core volume (IRR 1.35, 99% CI 1.24 to 1.46) were positively associated with the decision to treat with EVT. Interventionalists (IRR 1.26, 99% CI 1.01 to 1.56) were more likely to treat patients with MeVO immediately with EVT. In the dominance analysis, factors influencing the decision in favor of EVT were (in order of importance): baseline NIHSS, core volume, alteplase use, patients' age, and occlusion site. CONCLUSIONS Most physicians in this survey were interventionalists and would treat patients with MeVO stroke immediately with EVT. This finding supports the need for robust clinical evidence.
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Affiliation(s)
- Petra Cimflova
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Medical Imaging, Fakultní nemocnice u sv Anny v Brně, Brno, Czech Republic
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands.,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Nishita Singh
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Nima Kashani
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.,Neuroradiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Johanna Maria Ospel
- Radiology and Nuclear Medicine, Universitatsspital Basel, Basel, Switzerland
| | - Rosalie McDonough
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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9
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Ospel JM, Goyal M. A review of endovascular treatment for medium vessel occlusion stroke. J Neurointerv Surg 2021; 13:623-630. [PMID: 33637570 DOI: 10.1136/neurintsurg-2021-017321] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022]
Abstract
Medium-vessel occlusions (MeVOs), that is, occlusions of the M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery segments, account for 25%-40% of all acute ischemic stroke cases. Clinical outcomes of MeVO stroke with intravenous thrombolysis, which is the current standard of care, are moderate at best. With improving imaging technologies and a growing literature, MeVOs are increasingly recognized as a target for endovascular treatment (EVT). For the time being, there is limited but promising evidence for the safety and efficacy of MeVO EVT, and many neurointerventionists are already routinely offering EVT for MeVO stroke, despite the lack of clear guideline recommendations. In this article, we review the evidence on endovascular treatment for MeVO stroke and summarize the available literature on current imaging strategies, commonly used EVT selection criteria, EVT techniques, and outcome assessment for MeVO stroke.
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Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neuroscienes, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Clinical Neuroscienes, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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10
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Goyal M, Ospel JM. Adapting pre-hospital stroke triage systems to expanding thrombectomy indications. Neuroradiology 2021; 63:161-166. [PMID: 33439296 DOI: 10.1007/s00234-021-02638-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada. .,Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.
| | - Johanna M Ospel
- , Calgary, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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11
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Goyal M, Marko M. Optimising prehospital stroke triage in a changing landscape. Lancet Neurol 2021; 20:166-168. [PMID: 33422192 DOI: 10.1016/s1474-4422(20)30488-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences and Department of Radiology, University of Calgary, Calgary, AB T2N 1N4, Canada.
| | - Martha Marko
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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12
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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