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Xu Y, Liu X, Li H. A comparison of endovascular therapy and medical management in patients with large vessel occlusion mild stroke treated between 2015 and 2023: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107721. [PMID: 38616013 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024] Open
Abstract
OBJECTIVE Endovascular therapy (EVT) is recommended for patients with acute large-vessel occlusion (LVO) However, its efficacy and safety compared to medical management (MM) in patients with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 remains unclear. This meta-analysis compared EVT with medical MM in patients with large vessel occlusion mild stroke treated between 2015 and 2023, following the publication of the first randomized controlled trial. MATERIALS AND METHODS Biomedical database searches (inception to March 21, 2023) retrieved articles reporting favorable functional outcome(modified Rankin Scale [mRS] 0-1) and functional independence (mRS 0-2), 90-day mortality and symptomatic intracranial hemorrhage (sICH). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) to maintain methodological rigor and transparency in our meta-analysis. RESULTS We conducted a meta-analysis of 22 studies (4,985 patients) to reveal no significant differences in favorable functional outcomes and independence across all groups. However, in patients treated between 2015 and 2023, EVT exhibited a higher risk of 90-day mortality (Odds Ratio [OR] = 1.84, 95% Confidence Interval [CI] [1.10, 3.07], p = 0.02) and sICH (OR = 3.36, 95% CI [1.96, 6.66], p < 0.01). EVT correlated with elevated sICH in the anterior circulation (OR=2.94, 95%CI [1.82, 4.74], p<0.01) regardless of the proximal (OR=2.20, 95%CI [1.04, 4.69], p=0.04) or distal (OR=3.44, 95%CI [1.43, 8.32], p<0.01) location of the occlusion. EVT correlated with elevated sICH rates in patients treated within 6 hours of symptom onset or those with NHISS≤5. CONCLUSION In patients treated between 2015 and 2023, EVT and MM did not differ in efficacy in acute LVO mild stroke; MM associated with better safety outcomes. Rigorous randomized controlled trials are warranted.
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Affiliation(s)
- Yiqiao Xu
- Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China; Capital Medical University, Beijing, PR China
| | - Xin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Hao Li
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China.
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2
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Valente I, Alexandre AM, Colò F, Brunetti V, Frisullo G, Camilli A, Falcou A, Scarcia L, Gigli R, Scala I, Rizzo PA, Abruzzese S, Milonia L, Piano M, Macera A, Ruggiero M, Da Ros V, Bellini L, Lazzarotti GA, Cosottini M, Caragliano AA, Vinci SL, Gabrieli JD, Causin F, Panni P, Roveri L, Limbucci N, Arba F, Renieri L, Ferretti S, Pileggi M, Bianco G, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Fasano A, Lafe E, Cavallini AM, Mazzacane F, Russo R, Bergui M, Broccolini A, Pedicelli A. Effect of General Anesthesia Versus Conscious Sedation/Local Anesthesia on the Outcome of Patients with Minor Stroke and Isolated M2 Occlusion Undergoing Immediate Thrombectomy: A Retrospective Multicenter Matched Analysis. World Neurosurg 2024; 183:e432-e439. [PMID: 38154680 DOI: 10.1016/j.wneu.2023.12.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT). METHODS The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale score ≤5 who received iMT. Propensity score matching was used to estimate the effect of GA versus CS/LA on clinical outcomes and procedure-related adverse events. The primary outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-1. Secondary outcome measures were a 90-day mRS score of 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage, intraprocedural dissections, and new territory embolism. RESULTS Of the 172 patients who were selected, 55 received GA and 117 CS/LA. After propensity score matching, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion, and procedural-related complications between patients receiving GA or LA/CS (mRS score 0-1, P = 0.815; mRS score 0-2, P = 0.401; all-cause mortality, P = 0.408; modified Treatment in Cerebral Infarction score 2b-3, P = 0.374; symptomatic subarachnoid hemorrhage, P = 0.082; intraprocedural dissection, P = 0.408; new territory embolism, P = 0.462). CONCLUSIONS In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.
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Affiliation(s)
- Iacopo Valente
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea M Alexandre
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Colò
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Arianna Camilli
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Anne Falcou
- Stroke Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Riccardo Gigli
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Irene Scala
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Pier A Rizzo
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Serena Abruzzese
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Luca Milonia
- Interventional Neuroradiology Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Guido A Lazzarotti
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, AOU Policlinico G. Martino, Messina, Italy
| | - Joseph D Gabrieli
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Pietro Panni
- Interventional Neuroradiology Unit and Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Luisa Roveri
- Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, Stroke Unit, A.O.U. Careggi, Firenze, Italy
| | | | - Leonardo Renieri
- Interventional Neurovascular Unit, Stroke Unit, A.O.U. Careggi, Firenze, Italy
| | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Marco Pileggi
- Neuroradiology Unit and Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Daniele G Romano
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit and Neuroradiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | - Emilio Lozupone
- Neuroradiology Unit and Neurology Unit, Vito Fazzi Hospital, Lecce, Italy
| | | | - Elvis Lafe
- Neuroradiology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna M Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | | | - Riccardo Russo
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Aldobrando Broccolini
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy; Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Alessandro Pedicelli
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
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Pujara DK, Al-Shaibi F, Sarraj A. Is thrombectomy indicated in all ischemic stroke with large vessel occlusion? Curr Opin Neurol 2024; 37:8-18. [PMID: 38054587 DOI: 10.1097/wco.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
PURPOSE OF REVIEW Purpose of this topical review is to examine the current randomized and nonrandomized evidence evaluating endovascular thrombectomy (EVT) in selected patient populations with acute ischemic stroke due to large vessel occlusions. RECENT FINDINGS After establishing EVT as the first-line treatment in patients with large vessel occlusions and limited ischemic changes on neuroimaging, recent trials successfully demonstrated efficacy and safety in patients with large core strokes and those with basilar occlusions up to 24 h of last known well. Nonrandomized evidence in patients with mild stroke severity, baseline disability, medium and distal vessel occlusions and time from last known well >24 h also suggested potential benefit of EVT in selected patients. Further randomized evidence will help establish EVT efficacy and safety in these populations. SUMMARY EVT is established as the de-facto treatment of choice in a significant proportion of patients presenting with acute ischemic stroke due to a large vessel occlusion and has shown potential benefits in additional patient subgroups. A rigorous risk-benefit assessment and discussions with patients and their families in the absence of randomized evidence should help facilitate an informed, individualized decision-making process for this revolutionary treatment in peripheral patient subgroups with limited evidence.
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Affiliation(s)
| | - Faisal Al-Shaibi
- University Hospitals Neurological Institute
- Case Western Reserve University School of Medicine, Department of Neurology, Cleveland, Ohio, USA
- King Abdulaziz University, Department of Neurology, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- University Hospitals Neurological Institute
- Case Western Reserve University School of Medicine, Department of Neurology, Cleveland, Ohio, USA
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Loh EDW, Toh KZX, Kwok GYR, Teo YH, Teo YN, Goh C, Syn NL, Ho AFW, Sia CH, Sharma VK, Tan BY, Yeo LL. Endovascular therapy for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e452-e459. [PMID: 36539273 DOI: 10.1136/jnis-2022-019717] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
AIMS Endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is a potential frontier of acute ischemic stroke (AIS) treatment, but its efficacy against best medical therapy (BMT) remains unknown. We performed a systematic review and meta-analysis evaluating the efficacy and safety of EVT versus BMT in primary DMVO. METHODS We systematically searched PubMed, Cochrane Library and Embase, from inception to August 14, 2022, for studies comparing EVT with BMT in DMVO-AIS. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (90-day modified Rankin Scale (mRS) 0-2) and excellent functional outcomes (90-day mRS 0-1). Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS Fourteen observational and two randomized-controlled studies were included, with 1202 patients receiving EVT and 1267 receiving BMT. After trim-and-fill correction, EVT achieved significantly better odds of functional independence than BMT (adjusted OR 1.61, 95% CI 1.06 to 2.43). There were no significant differences in overall excellent functional outcomes (OR 1.23, 95% CI 0.88 to 1.71), sICH (OR 1.44, 95% CI 0.78 to 2.66), and mortality (OR 1.03, 95% CI 0.73 to 1.45). Stratified by EVT method, mechanical thrombectomy±intra-arterial thrombolysis achieved more excellent functional outcomes than BMT (OR 1.59, 95% CI 1.13 to 2.23). In mild strokes (National Institutes of Health Stroke Scale score <6), EVT caused significantly more sICH (OR 6.30, 95% CI 1.55 to 25.64). CONCLUSIONS EVT shows promising efficacy benefit over BMT for primary DMVO-AIS. Further randomized controlled trials are necessary to evaluate the efficacy and safety of EVT in DMVO-AIS.
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Affiliation(s)
- Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Institute of Health Sciences Education, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L Syn
- Department of Surgery, National University Health System, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Vijay Kumar Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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5
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Qin B, Zhang Y, Liang S, Liang H, Tang S, Liang Z. Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:e475-e483. [PMID: 36813553 DOI: 10.1136/jnis-2022-019959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown. OBJECTIVE To conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO. METHODS EMBASE, Cochrane Library, PubMed, and Clinicaltrials.gov databases were searched until October 2022. Both retrospective and prospective studies which compared the clinical outcomes between EVT and medical treatment were included. ORs and 95% confidence intervals (CIs) for excellent and favorable functional outcomes, symptomatic intracranial hemorrhage (ICH), and mortality were pooled using a random-effects model. A propensity score (PS)-based methods adjusted analysis was also performed. RESULTS 4335 patients from 14 studies were included. In patients with mild stroke and AACLVO, EVT presented no marked differences in excellent and favorable functional outcomes and mortality compared with medical treatment. A higher risk of symptomatic ICH (OR=2.79; 95% CI 1.49 to 5.24; P=0.001) was observed with EVT. Subgroup analysis revealed that EVT had potential benefit for proximal occlusions with excellent functional outcomes (OR=1.68; 95% CI 1.01 to 2.82; P=0.05). Similar results were observed when PS-based methods adjusted analysis was used. CONCLUSION EVT did not significantly benefit clinical functional outcomes in comparison with medical treatment in patients with mild stroke and AACLVO. However, it may improve functional outcomes when treating patients with proximal occlusion, despite being associated with an increased risk of symptomatic ICH. Stronger evidence from ongoing randomized controlled trials is required.
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Affiliation(s)
- Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yunli Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shiting Tang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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7
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Safouris A, Palaiodimou L, Nardai S, Kargiotis O, Magoufis G, Psychogios K, Matusevicius M, Feil K, Ahmed N, Kellert L, Spiliopoulos S, Brountzos E, Szikora I, Sarraj A, Goyal N, Aguiar de Sousa D, Strbian D, Caso V, Alexandrov AV, Tsivgoulis G. Medical Management Versus Endovascular Treatment for Large-Vessel Occlusion Anterior Circulation Stroke With Low NIHSS. Stroke 2023; 54:2265-2275. [PMID: 37526011 DOI: 10.1161/strokeaha.123.043937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/08/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with National Institutes of Health Stroke Scale score of 0 to 5 is common in clinical practice but has not yet been proven safe and effective. Our objective is to assess whether EVT on top of best medical treatment (BMT) in AIS patients with large-vessel occlusion of the anterior circulation presenting with mild symptoms is beneficial compared with BMT. METHODS We searched MEDLINE, SCOPUS, and reference lists of retrieved articles published until December 28, 2022. A systematic literature search was conducted to identify clinical trials or observational cohort studies evaluating patients with AIS due to anterior circulation large-vessel occlusion and admission National Institutes of Health Stroke Scale score ≤5 treated with EVT versus BMT alone. The primary outcome was excellent functional outcome (modified Rankin Scale score 0-1) at 3 months. The protocol had been registered before data collection (PROSPERO). RESULTS Eleven observational eligible studies were included in the meta-analysis, comprising a total of 2019 AIS patients with National Institutes of Health Stroke Scale score ≤5 treated with EVT versus 3171 patients treated with BMT. EVT was not associated with excellent functional outcome (risk ratio, 1.10 [95% CI, 0.93-1.31]). When stratified for different study design (per-protocol versus intention-to-treat), there were no significant subgroup differences. EVT was not associated with good functional outcome (modified Rankin Scale score 0-2; risk ratio, 1.01 [95% CI, 0.89-1.16]) or reduced disability at 3 months (common odds ratio, 0.92 [95% CI, 0.60-1.41]). Symptomatic intracranial hemorrhage was more common in the patients receiving EVT (risk ratio, 3.53 [95% CI, 2.35-5.31]). No correlation was found between EVT and mortality at 3 months (risk ratio, 1.34 [95% CI, 0.83-2.18]). The same overall associations were confirmed in the sensitivity analysis of studies that performed propensity score matching. CONCLUSIONS EVT appears equivalent to BMT for patients with anterior circulation large-vessel occlusion AIS with low baseline National Institutes of Health Stroke Scale, despite the increased risk for symptomatic intracranial hemorrhage. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022334417.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A. Safouris, O.K., K.P.)
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A. Safouris, L.P., G.T.)
- Department of Neurosurgery, National Institute of Mental Health, Neurology and Neurosurgery, Department Section of Neurointervention, Semmelweis University, Budapest, Hungary (A. Safouris, S.N., I.S.)
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A. Safouris, L.P., G.T.)
| | - Sándor Nardai
- Department of Neurosurgery, National Institute of Mental Health, Neurology and Neurosurgery, Department Section of Neurointervention, Semmelweis University, Budapest, Hungary (A. Safouris, S.N., I.S.)
| | - Odysseas Kargiotis
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A. Safouris, O.K., K.P.)
| | - George Magoufis
- Neuroradiology Department, Metropolitan Hospital, Piraeus, Greece (G.M.)
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece (G.M., S.S., E.B.)
| | | | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.)
| | - Katharina Feil
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Munich, Germany (K.F., L.K.)
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT), Germany (K.F.)
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.)
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Munich, Germany (K.F., L.K.)
| | - Stavros Spiliopoulos
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece (G.M., S.S., E.B.)
| | - Elias Brountzos
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece (G.M., S.S., E.B.)
| | - István Szikora
- Department of Neurosurgery, National Institute of Mental Health, Neurology and Neurosurgery, Department Section of Neurointervention, Semmelweis University, Budapest, Hungary (A. Safouris, S.N., I.S.)
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, OH (A. Sarraj)
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH (A. Sarraj)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.V.A., G.T.)
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic, Memphis (N.G.)
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, and Faculty of Medicine, University of Lisbon, Portugal (D.A.D.S.)
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland (D.S.)
| | - Valeria Caso
- Stroke Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.V.A., G.T.)
- Department of Neurology, Banner University Hospital, University of Arizona, Phoenix (A.V.A.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A. Safouris, L.P., G.T.)
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.V.A., G.T.)
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Wang P, Chen W, Chen C, Bivard A, Yu G, Parsons MW, Lin L. Association of Perfusion Lesion Variables With Functional Outcome in Patients With Mild Stroke and Large Vessel Occlusion Managed Medically. Neurology 2023; 100:e627-e638. [PMID: 36307224 PMCID: PMC9946183 DOI: 10.1212/wnl.0000000000201498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The best management of patients with mild stroke and large vessel occlusion (LVO) remains unclear. This study aimed to identify perfusion imaging predictors of poor functional outcome in such patients. METHODS This cohort study retrospectively selected patients enrolled in the International Stroke Perfusion Imaging Registry between August 2011 and April 2022. The registry enrolled patients with acute ischemic stroke and with baseline CT perfusion scanned within 24 hours of stroke onset. This study identified patients with mild symptoms, defined by an NIH Stroke Scale score of ≤5. Patients with LVO of anterior circulation were selected. This study further selected patients who received medical management and excluded patients who received endovascular treatment. The primary outcome was poor functional outcome defined as a modified Rankin Scale of 3-6 at 3 months. Perfusion lesion was defined by delay time > 3 seconds on CTP. Regression analyses were used to identify clinical and imaging variables that predicted poor functional outcome. RESULTS A total of 139 patients with mild stroke were included, of whom 27 (19%) had poor functional outcome. Patients with poor outcome, compared with those with good outcome, had much larger perfusion lesion volume (median 80 mL vs 41 mL, p < 0.001). Perfusion lesion was a significant predictor of poor outcome in either univariable regression (crude OR = 1.02, 95% CI = [1.01-1.03]) or multivariable regression model (adjusted OR = 1.01, 95% CI = [1.01-1.02]), adjusting for occlusion site, good collaterals, baseline stroke severity, age, IV thrombolysis (IVT), and onset to scan time. A perfusion lesion of 65 mL was the optimal cutpoint to identify poor functional outcome (sensitivity = 59%, specificity = 77%). Patients with perfusion lesion ≥65 mL, compared with patients with perfusion lesion <65 mL, showed a much higher rate of poor functional outcome (38% vs 11%, p < 0.001). Of the 139 patients in this study, 95 received IVT. Patients treated with or without IVT did not influence their outcomes (crude OR = 0.74, 95% CI = [0.31-1.78]). DISCUSSION A perfusion lesion of ≥65 mL predicted poor functional outcome in mild stroke patients with LVO.
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Affiliation(s)
| | | | | | | | | | | | - Longting Lin
- From the Department of Neurology (P.W., G.Y.), Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College); Zhangzhou Affiliated Hospital of Fujian Medical University (W.C.), China; Faculty of Health (C.C., M.W.P., L.L.), University of Newcastle; Melbourne Brain Centre (A.B.), University of Melbourne; and South Western Sydney Clinical School (M.W.P., L.L.), University of New South Wales, Australia.
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