Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site

Endovascular versus medical management of posterior cerebral artery occlusion stroke

PURPOSE

Endovascular treatment (EVT) of posterior cerebral artery (PCA) strokes is uncertain. We present our single-center experience with acute ischemic strokes (AIS) caused by PCA occlusion.

METHODS

This study included consecutive patients with PCA occlusion presenting within 24 hours of time last well-known from January 2017 to June 2024. Patients treated with EVT, or medical management (MM) were compared with multivariable logistic regression and inverse probability of treatment weighting. The primary outcome was the 90-day modified Rankin Scale (mRS) score. The safety outcomes were symptomatic intracranial hemorrhage (sICH) and mortality.

RESULTS

Overall, 53 patients were treated with MM and 16 with EVT. The 90-day mRS score of 0-2 was seen in 43.8 % of the EVT and 67.3 % in the MM group (p = 0.90). There was a higher rate of early decrease in NIHSS score ≥ 2 points was observed in the EVT group, but this was not statistically significant. Vision recovery was similar between groups. One patient had symptomatic ICH, and one patient underwent decompression due to edema. The proportion of patients with non-symptomatic ICH was higher in the EVT group (p = 0.025). Admission NIHSS > 6 was significantly associated with poor prognosis and mortality(p < 0.001).

CONCLUSION

Our results show no difference in functional outcome at 90 day between EVT and MM groups. We could not demonstrate a significant difference in sICH and mortality. EVT can be safe in PCA occlusion especially with admission NIHSS > 6.

Endovascular Therapy for Late-Window M2-Segment Middle Cerebral Artery Occlusion: Analysis of the CLEAR Study

BACKGROUND

There is uncertainty about whether patients with M2 occlusion benefit from endovascular therapy (EVT) in the late (6-24-hour) time window. We evaluated the clinical outcomes of patients with M2 occlusion selected for EVT compared with those who received medical management (MM) in the late window.

METHODS

This multinational cohort study was conducted at 66 sites across 10 countries (January 2014 to May 2022). We included consecutive patients with late-window stroke due to M2 occlusion, baseline National Institutes of Health Stroke Scale score of ≥5, and premorbid modified Rankin Scale score of ≤2 who received EVT or MM alone. The primary end point was 90-day ordinal shift in the modified Rankin Scale score. Safety end points were symptomatic intracranial hemorrhage and 90-day mortality. Differences in outcomes were determined using inverse probability of treatment weighting-adjusted logistic regression models.

RESULTS

Among 5098 patients, 496 met inclusion criteria (median [interquartile range] age, 74 years [62-81 years]; baseline National Institutes of Health Stroke Scale score, 12 [8-17]), of whom 394 (79.4%) received EVT and 102 (20.6%) MM. In inverse probability of treatment weighting adjusted analyses, there was no favorable 90-day ordinal modified Rankin Scale shift (odds ratio, 1.39 [95% CI, 0.92-2.12]) and no difference of functional independence rates (modified Rankin Scale score of 0-2; odds ratio, 1.72 [95% CI, 0.93-3.15]) with EVT compared with MM. Moreover, symptomatic intracranial hemorrhage risk (odds ratio, 3.46 [95% CI, 0.50-23.92]) and 90-day mortality (odds ratio, 1.11 [95% CI, 0.66-1.87]) were not statistically different between treatment groups.

CONCLUSIONS

In patients with M2 occlusion in the 6- to 24-hour time window, there was no difference in disability outcomes or symptomatic intracranial hemorrhage risk between patients treated with EVT compared with MM. Results of ongoing randomized trials will provide further insight.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.

Endovascular treatment in acute intracranial distal medium vessel occlusion stroke: Study protocol and rationale

BACKGROUND

Distal medium vessel occlusions (MeVOs) account for an estimated 25% to 40% of all acute ischemic strokes. Emerging evidence from non-randomized trials suggest that endovascular thrombectomy (EVT) can achieve high rates of successful reperfusion in MeVO strokes, with a safety profile comparable to EVT for proximal arterial occlusions. These findings underscore the need for a prospective randomized clinical trial to evaluate the safety and efficacy of EVT for MeVO stroke.

OBJECTIVE

This trial aims to evaluate the safety and efficacy of EVT for MeVO stroke.

METHODS AND DESIGN

Endovascular treatment in acute intracranial distal medium vessel occlusion stroke (ORIENTAL-MeVO) is an investigator-initiated, multicenter, prospective, randomized clinical trial with open-label treatment and blinded endpoint assessment (PROBE). Up to 564 eligible patients will be consecutively randomized in a 1:1 ratio to receive either EVT or standard of care over a period of 2 years in over 50 comprehensive stroke centers in China.

OUTCOMES

The primary outcome is a shift in the distribution of the modified Rankin Scale (mRS) at day 90s with levels 5-6 combined (mRS = 0, 1, 2, 3, 4, 5-6). Primary safety endpoints include symptomatic intracerebral hemorrhage at 24 h and mortality at 90 days.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06146790.

The Naples prognostic score as a nutritional and inflammatory biomarkers of stroke prevalence and all-cause mortality: insights from NHANES

BACKGROUND

Stroke is a complex neurological condition characterized by high rates of incidence, recurrence, disability, and mortality, making it one of the leading causes of death and disability worldwide. The Naples prognostic score (NPS), an index that combines markers of inflammation and nutritional status, has demonstrated prognostic value in various diseases. This research investigated the relationships among NPS, stroke prevalence, and overall mortality in stroke individuals, drawing on data from the National Health and Nutrition Examination Survey from 2007 to 2018.

METHODS

The cross-sectional analysis included 20,798 participants aged beyond 40 years with 1155 persons with stroke analyzed for mortality. Stroke prevalence was self-reported, and the NPS was derived from serum albumin, total cholesterol, the neutrophil-to-lymphocyte ratio, and the lymphocyte-to-monocyte ratio (Galizia et al. in Cancer 60:1273-1284, 2017). Weighted Logistic regression and Cox models assessed associations among NPS, stroke, and mortality, adjusting for demographic and clinical factors.

RESULTS

Higher NPS scores were linked to increased stroke prevalence (OR 3.573, 95% CI 2.745-4.652, P < 0.001) and elevated all-cause mortality risk (HR 3.281, 95% CI 1.978-5.442, P < 0.001) in stroke individuals. The triglyceride-glucose index (TYG) significantly modified the relationship between the NPS and stroke prevalence.

CONCLUSION

This study supports the clinical utility of the NPS as a predictor of both stroke prevalence and all-cause mortality. The NPS may serve as a valuable tool for risk stratification in stroke prevention and long-term prognosis.

Predictors of poor outcome in acute stroke patients with posterior cerebral artery occlusion and medical management

BACKGROUND AND AIMS

The clinical evolution of acute ischemic stroke patients with isolated proximal posterior cerebral artery (PCA) occlusion treated with medical management alone has been poorly described. We aimed to determine the clinical and radiological factors associated with poor functional outcome in this population.

METHODS

We conducted a multicenter international retrospective study of consecutive stroke patients with isolated occlusion of the first (P1) or second (P2) segment of PCA admitted within 6 h from symptoms onset in 26 stroke centers in France, Switzerland, and the United States, treated with the best medical management alone. Poor functional outcome was defined as a modified Rankin scale (mRS) ⩾2 at 3 months or no return to pre-stroke mRS. The associations between pretreatment variables and poor outcome were studied in univariable and then multivariable analyses, as well as the association between poor outcome and key follow-up radiological variables.

RESULTS

Overall, 585 patients were included. The median age was 74 years (interquartile range (IQR) = 63-83), median National Institutes of Health Stroke Scale (NIHSS) was 6 (3-10), 80% received intravenous thrombolysis (IVT), and 22% and 78% had P1 and P2 occlusions, respectively. Poor outcome occurred in 56% of patients. In multivariable analysis focusing on pretreatment variables, age (adjusted odds ratio (OR) = 1.12 per 5-year increase [95% confidence interval (CI) = 1.05-1.20]; p = 0.001), NIHSS score (aOR = 1.12 per each point increase [1.08-1.18]; p < 0.001), infarct volume (aOR = 1.16 per 5 mL increase [1.07-1.25]; p < 0.001), and the lack of IVT use (aOR = 1.79 [1.10-2.94], p = 0.020) were independently associated with poor outcome. Regarding 24-h follow-up radiological variables, complete recanalization (defined as no clot in the vascular tree at or beyond the primary occlusive lesion, aOR = 0.37 [95% CI = 0.21-0.65], p < 0.001) and parenchymal hematoma occurrence (aOR = 2.37 [95% CI = 1.01-5.56], p = 0.048) were independently associated with poor 3-month outcome.

CONCLUSIONS

Poor outcome occurred in more than half of medically treated PCA-related acute stroke patients. Facilitating IVT use may improve functional outcome. Therapeutic approaches aimed at enhancing recanalization and reducing hemorrhagic transformation need to be studied in clinical trials.

Current gaps in acute reperfusion therapies

PURPOSE OF REVIEW

Advances in intravenous thrombolysis and endovascular thrombectomy have significantly reduced disability and improved outcomes associated with acute ischemic stroke.

RECENT FINDINGS

An expansion of indications for reperfusion therapies in select groups of patients to permit treatment in an extended time window, with large ischemic core, and with simplified imaging protocols have enabled a broader group of patients access to disability-sparing therapy. Cerebroprotection has had renewed development in the era of acute reperfusion.

SUMMARY

In this review, we highlight recent developments in stroke reperfusion research and related questions that are under study or remain unanswered.

Efficacy and safety outcomes of endovascular versus best medical treatment in posterior cerebral artery occlusion stroke

BACKGROUND

The management of acute ischemic stroke due to isolated posterior cerebral artery occlusion (iPCAO) remains a topic of debate. This study investigates the efficacy and safety of endovascular treatment (EVT) versus best medical treatment (BMT) in patients with iPCAO.

METHODS

A systematic search was conducted across electronic databases including PubMed, Embase, and the Cochrane Library. Controlled studies comparing EVT and BMT in patients with iPCAO were selected. The primary efficacy outcome assessed was excellent outcome, defined as a modified Rankin Scale (mRS) score of 0-1. The primary safety outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included functional independence (mRS 0-2), early neurological improvement (ENI), and mortality rates. Statistical analyses were conducted using random effects models.

RESULTS

Eleven retrospective cohort studies involving 1811 patients with EVT and 2871 patients with BMT were analyzed. Compared with BMT, EVT was associated with a higher likelihood of an excellent outcome (adjusted OR (aOR) 1.33, 95% CI 1.14 to 1.54) and ENI (aOR 1.66, 95% CI 1.39 to 1.98), but no significant difference in functional independence (aOR 1.02, 95% CI 0.88 to 1.18). Compared with BMT, EVT may not be associated with an increased risk of sICH in patients with iPCAO (aOR 1.34, 95% CI 0.60 to 3.02) or mortality (aOR 1.31, 95% CI 0.83 to 2.08), although heterogeneity was high.

CONCLUSIONS

EVT may improve the likelihood of an excellent outcome and ENI in patients with iPCAO. However, the potential risks of sICH and mortality warrant consideration. Randomized trials are required to establish the definitive efficacy and safety of EVT in this patient population.

Rescue therapy after failed thrombectomy in medium/distal vessel occlusions: A retrospective analysis of an international, multi-center registry

BACKGROUND

There are limited therapeutic options in cases of failed reperfusion (modified thrombolysis in cerebral infarction [mTICI] score < 2b) after stent-retriever and/or aspiration based endovascular treatment (EVT) for acute ischemic stroke. Despite the absence of data supporting its use, rescue therapy (balloon angioplasty and/or stent implantation) is often utilized in such cases. Studies are limited to large vessel occlusions, while the outcomes and complications after rescue therapy in medium/distal vessel occlusions (MDVOs) have not been reported. This study aims to report the outcomes of rescue therapy in MDVO stroke patients.

METHODS

We performed an analysis of the "Blood pressure and Antiplatelet medication management after reScue angioplasty after failed Endovascular treatment in Large and distal vessel occlusions with probable IntraCranial Atherosclerotic Disease" (BASEL ICAD) retrospective registry. All MDVO stroke patients were included in the analysis.

RESULTS

Out of the 718 registry patients, 87 (12.1%) presented with an MDVO. Fifty-six patients (64.4%) showed an occlusion of the M2 segment of the middle cerebral artery. Rescue stenting was performed in 78 patients (89.7%) while balloon angioplasty alone was performed in 9 patients (10.3%). Successful reperfusion (mTICI score ⩾ 2b) was achieved in 73 (83.9%) patients after rescue therapy. Symptomatic intracranial hemorrhage (sICH) occurred in 8 patients (9.2%) and post-treatment stent occlusion in 12 patients (13.8%). Ninety days mortality was 20.7%. Twenty-eight patients (32.2%) achieved functional independence at 90 days (modified Rankin Scale 0-2).

CONCLUSION

Rescue therapy with stenting and/or balloon angioplasty in patients undergoing EVT for isolated MDVO with suspected underlying intracranial atherosclerotic disease is an effective reperfusion strategy but is associated with complications and poor functional outcomes.

Rescue therapy after failed thrombectomy in medium/distal vessel occlusions: A retrospective analysis of an international, multi-center registry

Background:

There are limited therapeutic options in cases of failed reperfusion (modified thrombolysis in cerebral infarction [mTICI] score < 2b) after stent-retriever and/or aspiration based endovascular treatment (EVT) for acute ischemic stroke. Despite the absence of data supporting its use, rescue therapy (balloon angioplasty and/or stent implantation) is often utilized in such cases. Studies are limited to large vessel occlusions, while the outcomes and complications after rescue therapy in medium/distal vessel occlusions (MDVOs) have not been reported. This study aims to report the outcomes of rescue therapy in MDVO stroke patients.

Methods:

We performed an analysis of the “Blood pressure and Antiplatelet medication management after reScue angioplasty after failed Endovascular treatment in Large and distal vessel occlusions with probable IntraCranial Atherosclerotic Disease” (BASEL ICAD) retrospective registry. All MDVO stroke patients were included in the analysis.

Results:

Out of the 718 registry patients, 87 (12.1%) presented with an MDVO. Fifty-six patients (64.4%) showed an occlusion of the M2 segment of the middle cerebral artery. Rescue stenting was performed in 78 patients (89.7%) while balloon angioplasty alone was performed in 9 patients (10.3%). Successful reperfusion (mTICI score ⩾ 2b) was achieved in 73 (83.9%) patients after rescue therapy. Symptomatic intracranial hemorrhage (sICH) occurred in 8 patients (9.2%) and post-treatment stent occlusion in 12 patients (13.8%). Ninety days mortality was 20.7%. Twenty-eight patients (32.2%) achieved functional independence at 90 days (modified Rankin Scale 0–2).

Conclusion:

Rescue therapy with stenting and/or balloon angioplasty in patients undergoing EVT for isolated MDVO with suspected underlying intracranial atherosclerotic disease is an effective reperfusion strategy but is associated with complications and poor functional outcomes.

Basilar artery occlusion management: An international survey of gender influence on management

BACKGROUND

The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender.

METHODS

From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO.

RESULTS

Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p < .01).

CONCLUSIONS

Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.

Endovascular Treatment for Basilar Artery Occlusion

Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.

CLEAR Thrombectomy Score: An Index to Estimate the Probability of Good Functional Outcome With or Without Endovascular Treatment in the Late Window for Anterior Circulation Occlusion

BACKGROUND

With the expanding eligibility for endovascular therapy (EVT) of patients presenting in the late window (6-24 hours after last known well), we aimed to derive a score to predict favorable outcomes associated with EVT versus best medical management.

METHODS AND RESULTS

A multinational observational cohort of patients from the CLEAR (Computed Tomography for Late Endovascular Reperfusion) study with proximal intracranial occlusion (2014-2022) was queried (n=58 sites). Logistic regression analyses were used to derive a 9-point score for predicting good functional outcome (modified Rankin Scale score 0-2 or return to premorbid modified Rankin Scale score) at 90 days, with sensitivity analyses for prespecified subgroups conducted using bootstrapped random forest regressions. Secondary outcomes included 90-day functional independence (modified Rankin Scale score 0-2), poor outcome (modified Rankin Scale score 5-6), and 90-day survival. The score was externally validated with a single-center cohort (2014-2023). Of the 3231 included patients (n=2499 EVT), a 9-point score included age, early computed tomography ischemic changes, and stroke severity, with higher points indicating a higher probability of a good functional outcome. The areas under the curve for the primary outcome among EVT and best medical management subgroups were 0.72 (95% CI, 0.70-0.74) and 0.87 (95% CI, 0.84-0.90), respectively, with similar performance in the external validation cohort (area under the curve, 0.71 [95% CI, 0.66-0.76]). There was a significant interaction between the score and EVT for good functional outcome, functional independence, and poor outcome (all Pinteraction<0.001), with greater benefit favoring patients with lower and midrange scores.

CONCLUSIONS

This score is a pragmatic tool that can estimate the probability of a good outcome with EVT in the late window.

REGISTRATION

URL: https://www.Clinicaltrials.gov; Unique identifier: NCT04096248.