Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

Abstract

Background Acute ischemic stroke patients with a large-vessel occlusion but mild symptoms (NIHSS ≤ 6) pose a treatment dilemma between medical management and endovascular thrombectomy. Aims To evaluate the differences in clinical outcomes of endovascular thrombectomy-eligible patients with target-mismatch perfusion profiles who undergo either medical management or endovascular thrombectomy. Methods Forty-seven patients with acute ischemic stroke due to large-vessel occlusion, NIHSS ≤ 6, and a target-mismatch perfusion imaging profile were included. Patients underwent medical management or endovascular thrombectomy following treating neurointerventionalist and neurologist consensus. The primary outcome measure was NIHSS shift. Secondary outcome measures were symptomatic intracranial hemorrhage, in-hospital mortality, and 90-day mRS scores. The primary intention-to-treat and as-treated analyses were compared to determine the impact of crossover patient allocation on study outcome measures. Results Forty-seven patients were included. Thirty underwent medical management (64%) and 17 underwent endovascular thrombectomy (36%). Three medical management patients underwent endovascular thrombectomy due to early clinical deterioration. Presentation NIHSS ( P = 0.82), NIHSS shift ( P = 0.62), and 90-day functional independence (mRS 0–2; P = 0.25) were similar between groups. Endovascular thrombectomy patients demonstrated an increased overall rate of intracranial hemorrhage (35.3% vs. 10.0%; P = 0.04), but symptomatic intracranial hemorrhage was similar between groups ( P = 0.25). In-hospital mortality was similar between groups ( P = 0.46), though all two deaths in the medical management group occurred among crossover patients. Endovascular thrombectomy patients demonstrated a longer length of stay (7.6 ± 7.2 vs. 4.3 ± 3.9 days; P = 0.04) and a higher frequency of unfavorable discharge to a skilled-nursing facility ( P = 0.03) rather than home ( P = 0.05). Conclusions Endovascular thrombectomy may pose an unfavorable risk-benefit profile over medical management for endovascular thrombectomy-eligible acute ischemic stroke patients with mild symptoms, which warrants a randomized trial in this subpopulation.

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

“…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%.…”

“…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%. [3][4][5][6][7][8][9][10] Second, and most importantly, we elected to assign patients to the treatment group in which they were intended on decision making, at variance with most earlier studies. [5][6][7]9,10 Accordingly, almost 1 in 10 patients in the intended IVT alone group eventually underwent rescue EVT, whereas 1 in 3 patients in the intended bridging group eventually did not receive EVT mainly because of early post-IVT recanalization.…”

“…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.…”

“…[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. However, the three studies that used the intention-to-treat design mixed patients treated with and without IVT, 3,4,8 precluding a specific assessment of the additional benefit of intended EVT in patients eligible for IVT-the most frequent minor stroke with LVO subgroup in clinical practice in the 0 to 4.5 hour time window.…”

“…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. However, the three studies that used the intention-to-treat design mixed patients treated with and without IVT, 3,4,8 precluding a specific assessment of the additional benefit of intended EVT in patients eligible for IVT-the most frequent minor stroke with LVO subgroup in clinical practice in the 0 to 4.5 hour time window. Moreover, these studies only included patients admitted in comprehensive stroke centers (ie, with EVT facility), and their results, therefore, do not apply to patients managed in primary stroke centers, which are currently the most common.…”