Endovascular thrombectomy or bridging therapy in minor ischemic stroke with large vessel occlusion

Association of blood pressure parameters on early neurological deterioration in patients with mild stroke and large vessel occlusion following medical management

OBJECTIVE

To explore the association between blood pressure (BP) metrics and early neurological deterioration of ischemic origin (ENDi) in patients with mild stroke and large vessel occlusion (LVO) undergoing best medical management (BMM).

METHODS

Data were collected from consecutive patients with mild stroke and LVO treated with BMM from January 2019 to December 2023. Admission systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and 24-h SBP variability were calculated. ENDi was defined as an National Institutes of Health Stroke Scale (NIHSS) score increase of ≥ 4 points within 24 h, excluding intracranial hemorrhage.

RESULTS

Among 347 patients, ENDi occurred in 42 (12.1%). The ENDi group exhibited higher admission SBP (158 vs. 131 mmHg, P < 0.001), SBP variability (32 vs. 14 mmHg, P < 0.001), and Tmax > 6 s volumes (63 vs. 40 ml, P < 0.001), and a greater proportion had vertebrobasilar occlusion (42.9% vs. 12.1%, P < 0.001). Multivariable analysis indicated that patients in the highest quartile for admission SBP (adjusted odds ratio [aOR] = 2.47, 95% confidence interval [CI] = 1.47-4.29), SBP variability (aOR = 2.57, 95% CI = 1.34-5.18), and Tmax > 6 s volumes (aOR = 2.09, 95% CI = 1.28-5.89) were independently associated with ENDi. Significant association also existed between vertebrobasilar occlusion and ENDi (aOR = 3.19, 95% CI = 1.76-6.74).

CONCLUSION

Significantly elevated admission SBP and large SBP variability were associated with the occurrence of ENDi in patients with mild stroke and LVO receiving BMM.

Comparing the efficacy and safety of bridging therapy vs. monotherapy in patients with minor stroke: a meta-analysis

The two main therapeutic approaches for stroke treatment are endovascular thrombectomy, which involves mechanically removing the thrombus, and bridging therapy, which uses intravenous thrombolytics (IVT) prior to endovascular thrombectomy (EVT). This study aimed to compare monotherapy (EVT or IVT alone) with bridging therapy (IVT+EVT) in terms of efficacy and safety outcomes in patients with minor ischemic stroke. After a thorough screening, eight studies were included for qualitative synthesis and meta-analysis, comprising a total of 3,117 patients across the treatment arms. The main outcomes of interest were the efficacy of treatment modality, the rate of intracerebral hemorrhage (ICH), and mortality. In terms of functional outcomes measured by the Modified Rankin Score (mRs) 0-1, no significant difference was observed when comparing IVT monotherapy with bridging therapy (IVT+EVT), with an odds ratio of 0.79 (P = 0.41). However, IVT was associated with a decreased risk of symptomatic intracranial hemorrhage (sICH) compared to bridging therapy (OR = 0.51; P = 0.02), while EVT was associated with an increased risk of sICH compared to bridging therapy (OR = 8.33; P = 0.01). Mortality rates were comparable between IVT alone compared to bridging therapy and EVT alone compared to bridging therapy (P = 0.14). Although both treatment modalities share similar efficacy, there was a trend in favoring bridging therapy for mortality rates, but it was not statistically significant. Future randomized controlled trials and updated systematic reviews are needed within five to ten years to increase sample sizes and potentially identify statistically significant differences in mortality and other outcomes.

External validation of the iScore, ASTRAL score, DRAGON score, and THRIVE score and development of a nomogram to predict outcome in patients with large vessel occlusion-acute ischemic stroke

OBJECTIVE

This study aimed to validate the iScore, ASTRAL score, DRAGON score, and THRIVE score for assessing large vessel occlusion-acute ischemic stroke (AIS-LVO) and establish a predictive model for AIS-LVO patients that has better performance to guide clinical practice.

METHODS

We retrospectively included 439 patients with AIS-LVO and collected baseline data from all of them. External validation of the iScore, ASTRAL score, DRAGON score, and THRIVE score was performed. All variables were compared between groups via univariate analysis, and the results are expressed as ORs and 95 % CIs. Independent variables with P < 0.25 were included in the multivariate logistic analysis, and statistically significant differences (P < 0.05) were identified as risk factors for prognosis in AIS-LVO patients. Receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA) were used to evaluate the predictive value of our model.

RESULTS

Our external validation resulted in an iScore under the curve (AUC) of 0.8475, an ASTRAL AUC of 0.8324, a DRAGON AUC of 0.8196, and a THRIVE AUC of 0.8039. In our research, multivariate Cox regression revealed 8 independent predictors. We used a nomogram to visualize the results of the data analysis. The AUC for the training cohort was 0.8855 (95 % CI, 0.8487-0.9222), and that in the validation cohort was 0.8992 (95 % CI, 0.8496-0. 9488).

CONCLUSIONS

In this study, we verified that the above scores have excellent efficacy in predicting the prognosis of AIS-LVO patients. The nomogram we developed was able to predict the prognosis of AIS-LVO more accurately and may contribute to personalized clinical decision-making and treatment for future clinical work.

Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion

BACKGROUND

Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone.

METHOD

We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies.

RESULT

76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0-1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66-0.86; p < 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25-1.65; p < 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621-1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594-0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity.

CONCLUSION

Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.

IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts

INTRODUCTION

The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation.

PATIENTS AND METHODS

Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed.

RESULTS

Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%).

CONCLUSIONS

Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.

Intravenous Thrombolysis or Medical Management for Minor Strokes

OBJECTIVE

 To evaluate the outcomes of acute ischemic stroke patients with minor deficits treated with either intravenous thrombolysis (IVT) or routine medical management (MM).

METHODS

 The study included patients with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less who were treated with IVT within 4.5 hours from symptom onset and were classified as the IVT group. The MM group consisted of an equal number of patients with minor strokes, matched for sex, age, and severity, who did not receive thrombolysis. Data on patient information were collected for both groups.

RESULTS

 A total of 26,236 patients were included in this study (13,208 in IVT and 13,208 in MM). Of these patients, 67.9% were men, and the mean age was 67.1 years (standard deviation: 10.9). At 3 months, the IVT group had a higher rate of stroke-independent outcome (Rankin Scale score of 0-2) compared with the MM group (IVT vs. MM: 91.6 vs. 88.6%, absolute difference: 2.5%, 95% confidence interval [CI]: 1.6-3.4%, p = 0.008; adjusted hazard ratio [HR]: 1.2, 95% CI: 1.1-1.4, p = 0.003). Furthermore, there was no significant difference in 3-month mortality rates between the IVT and MM groups (IVT vs. MM: 2.1 vs. 2.5%, absolute difference: -0.6%, 95% CI: -1.1 to 0.3%, p = 0.11; adjusted HR: 0.9, 95% CI: 0.8-1.2, p = 0.09).

CONCLUSION

 Compared with MM, IVT does not reduce mortality in minor ischemic stroke but improves functional outcomes in minor stroke with an NIHSS score of 3 to 5.