Background and Purpose: Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion (LVO) and NIHSS ≥6. However, EVT benefit for mild deficits LVOs (NIHSS<6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with LVO. Methods: A retrospective cohort of patients with anterior circulation LVO and NIHSS<6 presenting within 24hours from last-seen-normal were pooled. Patients were divided into 2 groups: EVT or medical management. 90day mRS=0–1 was the primary outcome; mRS=0–2 was the secondary. Symptomatic intracerebral hemorrhage (sICH) was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time-last-seen-normal-to-presentation, center, IV-alteplase, ASPECTS, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results: 214 patients (EVT-124, medical management-90) were included from 8 US and Spain centers between January/2012 and March/2017. The groups were similar in age, ASPECTS, IV-alteplase rate and time-last-seen-normal-to-presentation. There was no difference in mRS=0–1 between EVT and medical management (55.7% versus 54.4%, respectively, aOR=1.3, 95%CI=0.64–2.64, p=0.47). Similar results were seen for mRS=0–2 (63.3% EVT versus 67.8% medical management, aOR=0.9, 95%CI=0.43–1.88, p=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5%EVT, 48.4% medical management; OR=1.17, 95%CI=0.54–2.52, p=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance (p=0.07). sICH rates were higher with thrombectomy (5.8% EVT versus 0% medical management, p=0.02). Conclusions: Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS<6) receiving thrombectomy irrespective of thrombus location, with increased sICH rates, consistent with the guidelines recommending the treatment for NIHSS≥6. There was a signal towards benefit with EVT only in M1 occlusions; however this needs to be further evaluated in future RCTs.
Christian Johann Doppler, a mathematician, physician, and astronomer, first described the Doppler principle in 1843. Its use in neurology was first reported in 1982, 1 and since then, its convenience and growing range of uses have made it an attractive tool to evaluate the cerebrovascular tree in patients with neurovascular disorders. Transcranial Doppler (TCD) is a noninvasive ultrasound device that allows real-time evaluation of the intracranial cerebral circulation. It is currently under-utilized in part due to the lack of awareness about the diagnostic usefulness of this test. In this article, we will review TCD testing as a procedure and discuss its clinical applications of special interest to the primary care physician. Examination and Doppler InstrumentUltrasound examination of a vessel by means of TCD is referred to as insonation. The TCD probe is placed over different "acoustic windows" that are specific areas of skull where there is a lack of boney covering or the cranial bone is thin (Figure 1). The transtemporal (temporal) window is used to insonate the middle cerebral artery (MCA), the anterior cerebral artery (ACA), the posterior cerebral artery (PCA), and the terminal portion of the internal carotid artery (TICA), before its bifurcation. The transorbital (orbital) window gives access to insonate the ophthalmic artery (OA) as well as the internal carotid artery at the siphon level. The transforaminal (occipital) window allows insonation of the distal vertebral arteries (VA) and the basilar artery (BA). Finally, the submandibular window allows insonation of the more distal portions of the extracranial internal carotid artery. TCD does not allow direct visualization of insonated vessels like carotid Doplex, rather it is an indirect evaluation by means of an ultrasonic beam of 2 MHz frequency that is produced from piezoelectric crystals that have been stimulated electrically. This beam bounces off the erythrocytes within the insonated artery. The reflected signal is received by the transducer and converted to an electric signal (Figure 2). This information is subtracted from the transmitted signal and then processed to obtain a waveform that allows accurate determination of blood flow velocities, direction of flow, and also allows for certain calculated parameters to be added to the evaluation. The pulsatility index (PI) is one of the useful calculated parameters, and it is considered a reliable marker of resistance distal to the insonated site. It is usually calculated by the Gosling equation. 2 PI ϭ (Peak systolic velocity Ϫ end diastolic velocity)/mean velocity.
The FUNC and ICH-GS appear superior to the oICH in predicting outcome in patients with primary ICH. In addition, the FUNC score appears to accurately identify patients with low chance of functional neurologic recovery at discharge.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
customersupport@researchsolutions.com
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.