Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

Abstract

Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0-2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35). Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

A multicenter study of the safety and effectiveness of mechanical thrombectomy for patients with acute ischemic stroke not meeting top-tier evidence criteria

“…We recently reported that nearly 50% of patients who underwent MT would have been denied the procedure if top-tier guidelines were strictly followed at a single center 10. Interestingly, 33% of cases treated outside these guidelines achieved functional independence at 3 months and, importantly, the procedure was safe in this cohort without excessive risk for symptomatic intracerebral hemorrhage (sICH) 10.…”

Admission hyperglycemia and outcomes in large vessel occlusion strokes treated with mechanical thrombectomy

“…Functional outcome was evaluated at 3 months using the modified Rankin Scale (mRS) score. Functional improvement was assessed by the shift in the distribution of 3 month mRS score,25 while functional independence was defined as a 3 month mRS score of 0–2 19. The mRS scores were obtained either from a post hospital discharge clinic follow-up or from a hospital visit.…”

Do acute ischemic stroke patients receive the right treatment in non-stroke units?

“…•treatment that can be initiated within 6 hours of symptom onset (21) Selection of patients for endovascular treatment of acute ischemic stroke can be performed with the help of CT or MRI imaging.…”