Endovascular Thrombectomy for Mild Strokes: How Low Should We Go?

Sarraj, Amrou; Hassan, Ameer E.; Savitz, Sean I; Grotta, James C.; Cai, Chunyan; Parsha, Kaushik; Farrell, Christine; Imam, Bita; Sitton, Clark; Reddy, Sujan; Kamal, Haris; Goyal, Nitin; Elijovich, Lucas; Reishus, Katelin; Krishnan, Rashi; Sangha, Navdeep; Wu, Albert T.; Costa, Rogério A.; Malik, Ruqayyah; Mir, Osman; Hasan, Rashedul; Snodgrass, Lindsay; Requena, Manuel; Graybeal, Dion; Abraham, Michael; Chen, Michael; McCullough, Louise D.; Ribó, Marc

doi:10.1161/strokeaha.118.022114

Cited by 101 publications

(92 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Second, occlusion site significantly modified the effect of bridging therapy, namely the latter was associated with better functional outcome in proximal or distal M1 occlusions, and with worse functional outcome and higher odds of any ICH or sICH for M2 occlusions. The present work differs from previous observational studies in several key points, [3][4][5][6][7][8][9][10] precluding direct comparison of the results. First, it is the first to specifically assess the effect of EVT added on IVT-as compared to IVT alone, the currently recommended therapy in patients with disabling minor stroke 1 -in this population, as all the previously published observational studies mixed patients treated with and without IVT, with range of IVT-treated patients varying from 31 to 78%.…”

Section: Discussioncontrasting

confidence: 66%

“…Several observational studies have compared clinical outcome from EVT added on medical treatment versus medical treatment alone in this population. [3][4][5][6][7][8][9][10] However, an "intention-to-treat" design comparing intended EVT added on medical treatment (ie, including those patients who eventually did not receive EVT, because of, eg, post-IVT early recanalization) to intended medical treatment alone (ie, including those patients who eventually received EVT because of early neurological deterioration) was used in only three of the above studies. 3,4,8 Yet, using the intention-to-treat design is the only way to directly address the equipoise that faces the treating physician at the time of decision making.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Bridging Therapy or IV Thrombolysis in Minor Stroke with Large Vessel Occlusion

Seners

Perrin

Lapergue

et al. 2020

Annals of Neurology

View full text Add to dashboard Cite

Objective Whether bridging therapy (intravenous thrombolysis [IVT] followed by endovascular treatment) is superior to IVT alone in minor stroke with large vessel occlusion (LVO) is unknown. Methods Multicentric retrospective observational study including, in intention‐to‐treat, consecutive IVT‐treated minor strokes (National Institutes of Health Stroke Scale [NIHSS] ≤ 5) with LVO, with or without additional mechanical thrombectomy. Propensity‐score (inverse probability of treatment weighting) was used to reduce baseline between‐groups differences. The primary outcome was excellent outcome, that is, modified Rankin score 0 to 1 at 3 months follow‐up. Results Overall, 598 patients were included (214 and 384 in the bridging therapy and IVT groups, respectively). Following propensity‐score weighting, the distribution of baseline clinical and radiological variables was similar across the two patient groups. Compared with IVT alone, bridging therapy was not associated with excellent outcome (odds ratio [OR] = 0.96; 95% confidence interval [CI] = 0.75–1.24; p = 0.76), but was associated with symptomatic intracranial hemorrhage (OR = 3.01; 95% CI = 1.77–5.11; p < 0.0001). Occlusion site was a strong modifier of the effect of bridging therapy on outcome (pinteraction < 0.0001), with bridging therapy associated with higher odds of excellent outcome in proximal M1 (OR = 3.26; 95% CI = 1.67–6.35; p = 0.0006) and distal M1 (OR = 1.69; 95% CI = 1.01–2.82; p = 0.04) occlusions, but with lower odds of excellent outcome for M2 (OR = 0.53; 95% CI = 0.38–0.75; p = 0.0003) occlusions. Bridging therapy was associated with higher rates of symptomatic intracranial hemorrhage in M2 occlusions only (OR = 4.40; 95% CI = 2.20–8.83; p < 0.0001). Interpretation Although overall outcomes were similar in intended bridging therapy as compared to intended IVT alone in minor strokes with LVO, our results suggest that intended bridging therapy may be beneficial in M1 occlusions, whereas the benefit–risk profile may favor IVT alone in M2 occlusions. ANN NEUROL 2020 ANN NEUROL 2020;88:160–169

show abstract

Section: Discussioncontrasting

confidence: 66%

mentioning

confidence: 99%

Bridging Therapy or IV Thrombolysis in Minor Stroke with Large Vessel Occlusion

Seners

Perrin

Lapergue

et al. 2020

Annals of Neurology

View full text Add to dashboard Cite

show abstract

“…They reported no differences in the excellent (mRS: 0-1) or good (mRS: 0-2) outcome rates, and that the incidence of symptomatic hemorrhage was significantly higher in the thrombectomy group (5.8 vs. 0%, respectively). 26) However, subgroup analysis revealed that the excellent outcome rate was significantly higher in the thrombectomy group among patients with M1 occlusion (52.8 vs. 23.8%, respectively). The DEFUSE 3 study involving mild-status patients with an NIHSS score of 6-9 suggested the usefulness of thrombectomy in accordance with patient selection.…”

Section: Discussionmentioning

confidence: 90%

Two Patients Who Underwent Emergency Stenting for Iatrogenic Cervical Internal Carotid Artery Dissection during Thrombectomy

Tsujimoto

Ikeda

Otsuka

et al. 2020

JNET

View full text Add to dashboard Cite

Iatrogenic artery dissection during reperfusion therapy is one of the complications causing a poor prognosis. We report two cases of emergent stent placement for iatrogenic cervical carotid artery dissection during reperfusion therapy for acute ischemic stroke. Case Presentation: Two patients, a 77-year-old woman and a 77-year-old man, were diagnosed with acute major cerebral artery occlusion, and underwent reperfusion therapy. The iatrogenic internal carotid artery dissection was caused by derivation of a 6-Fr catheter and 0.014-inch wire in the tortuous cervical internal carotid artery, and emergent stent placement was performed. Recanalization was confirmed and no deterioration caused by the iatrogenic dissection was found. Conclusion: In patients in whom cerebral infarction is localized on MRI, additional stent placement may be effective for preventing adverse events caused by iatrogenic cervical internal carotid artery dissection during reperfusion therapy for intracranial cerebral artery occlusion related to atherosclerotic change. Keywords▶ acute ischemic stroke, carotid artery, iatrogenic dissection, reperfusion therapy, stent whether the treatment of a target lesion should be continued or whether iatrogenic artery dissection should be managed. 3) Several studies have suggested the usefulness of reperfusion therapy for anterior circulation major artery occlusion, 4-8) but iatrogenic artery dissection during this therapy may lead to an unfavorable outcome; this must always be considered. 9) Few studies have reported iatrogenic artery dissection during reperfusion therapy for acute cerebral infarction. 9-12) To our knowledge, no study has described the details of patients in whom emergency stenting for iatrogenic artery dissection led to a favorable postoperative course. In this study, we report two patients in whom emergency stenting for iatrogenic cervical internal carotid artery dissection, which occurred after introducing a 6-Fr catheter and 0.014-inch wire during reperfusion therapy for acute cerebral infarction, resulted in a favorable postoperative course. Case Presentation Case 1 The patient was a 77-year-old, right-handed female. There was no medical or smoking history. Dysarthria and paralysis of This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

show abstract

“…Recently, a multicenter cohort study reported that thrombectomy did not increase the likelihood of excellent functional outcomes in mild strokes (NIHSS < 6) irrespective of thrombus location, with rising symptomatic intracerebral hemorrhage rates in these patients (Sarraj et al, 2018). For minor stroke or TIA, it is difficult to distinguish those patients who have the chance to attain spontaneous recanalization within the time window.…”

Section: Discussionmentioning

confidence: 99%

“…For minor stroke or TIA, it is difficult to distinguish those patients who have the chance to attain spontaneous recanalization within the time window. Recently, a multicenter cohort study reported that thrombectomy did not increase the likelihood of excellent functional outcomes in mild strokes (NIHSS < 6) irrespective of thrombus location, with rising symptomatic intracerebral hemorrhage rates in these patients (Sarraj et al, 2018).…”

Section: Discussionmentioning

confidence: 99%

Reperfusion therapy for minor stroke: A systematic review and meta‐analysis

Lan

Rong

et al. 2019

Brain and Behavior

View full text Add to dashboard Cite

Objectives Approximately, half of the acute stroke patients with minor symptoms were excluded from thrombolysis in some randomized controlled trials (RCTs). There is little evidence on treating minor strokes with rt‐PA. Here, we performed a systematic review and meta‐analysis to assess the safety and efficacy of thrombolysis in these patients. Methods PubMed, Embase, Web of Science, and Cochrane Library were searched in July 2018. All available RCTs and retrospective comparative studies that compared thrombolysis with nonthrombolysis' for acute minor stroke (NIHSS ≤ 5) with quantitative outcomes were included. Results Ten studies, including a total of 4,333 patients, were identified. The risk of intracranial hemorrhage (ICH) was higher in the rt‐PA group as compared with that in the non‐rt‐PA group (3.8% vs. 0.6%; p = .0001). However, there is no significant difference in the rate of mortality between the two groups (p = .96). The pooled rate of a good outcome in 90 days was 67.8% in those with rt‐PA and 63.3% in those without rt‐PA (p = .07). Heterogeneity was 43% between the studies (p = .08). After adjusting for the heterogeneity, thrombolysis was associated with good outcome (68.3% vs. 63.0%, OR 1.47; 95% CI 1.14–1.89; p = .003). In post hoc analyses, including only RCTs, the pooled rate of good outcome had no significant differences between the two groups (86.6% vs. 85.7%, 95% CI 0.44–3.17, p = .74; 87.4% vs. 91.9%, 95% CI 0.35–1.41, p = .32; before and after adjusting separately). Conclusions Although thrombolysis might increase the risk of ICH based on existing studies, patients with acute minor ischemic stroke could still benefit from thrombolysis at 3 months from the onset.

show abstract

Endovascular Thrombectomy for Mild Strokes: How Low Should We Go?

Cited by 101 publications

References 22 publications

Bridging Therapy or IV Thrombolysis in Minor Stroke with Large Vessel Occlusion

Bridging Therapy or IV Thrombolysis in Minor Stroke with Large Vessel Occlusion

Two Patients Who Underwent Emergency Stenting for Iatrogenic Cervical Internal Carotid Artery Dissection during Thrombectomy

Reperfusion therapy for minor stroke: A systematic review and meta‐analysis

Contact Info

Product

Resources

About