Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis

Abstract

BackgroundThe 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.ObjectiveTo conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO.MethodsEMBASE, 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.Results4335 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.ConclusionEVT 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.

Evaluation of acute mechanical revascularization in minor stroke (NIHSS score ⩽ 5) and large vessel occlusion: The MOSTE multicenter, randomized, clinical trial protocol

“…However, MT benefit in patients with minor stroke (National Institutes of Health Stroke Scale, NIHSS, score ⩽ 5) remains uncertain because these patients were excluded from randomized clinical trials. 4–6 A recent meta-analysis of observational studies 7 suggests similar outcomes of MT and best medical treatment (BMT) in these patients. The site of occlusion can modify the effect of immediate MT, with a potential benefit for patients with more proximal occlusions.…”

“…The site of occlusion can modify the effect of immediate MT, with a potential benefit for patients with more proximal occlusions. 7 Therefore, the current guidelines recommend MT only for patients with NIHSS score ⩾ 6. 8,9 In case of worsening, patients who received BMT may undergo secondary MT, 2,10–12 but outcome and recanalization rate may be less good than with immediate MT.…”