Mechanical Thrombectomy for Large Ischemic Stroke

Li, Qi; Abdalkader, Mohamad; Siegler, James E.; Yaghi, Shadi; Sarraj, Amrou; Campbell, Bruce C.V.; Yoo, Albert J.; Zaidat, Osama O.; Kaesmacher, Johannes; Pujara, Deep; Nogueira, Raul G; Saver, Jeffrey L.; Li, Lei; Han, Qin; Dai, Yi; Sang, Hongfei; Yang, Qingwu; Nguyen, Thanh N.; Qiu, Zhongming

doi:10.1212/wnl.0000000000207536

Cited by 40 publications

(24 citation statements)

References 45 publications

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“…DOI: 10.1161/STROKEAHA.123.045015 patients having better outcomes compared with patients who present with larger core infarct. [34][35][36][37][38][39] In this study, similar to several previous studies, women exhibited older age, 40 higher rates of hypertension, and atrial fibrillation. 15,41 Additionally, they had greater prestroke disability, 42 and encountered longer time to imaging compared with men.…”

Section: Discussionsupporting

confidence: 89%

Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy

Abdalkader,

Ning,

Qureshi

et al. 2024

Stroke

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BACKGROUND: The association between sex and outcome after endovascular thrombectomy of acute ischemic stroke is unclear. The aim of this study was to compare the clinical and safety outcomes between men and women treated with endovascular thrombectomy in the late 6-to-24-hour window period. METHODS: This multicenter, retrospective observational cohort study included consecutive patients who underwent endovascular thrombectomy of anterior circulation stroke in the late window from 66 clinical sites in 10 countries from January 2014 to May 2022. The primary outcome was the 90-day ordinal modified Rankin Scale score. Secondary outcomes included 90-day functional independence (FI), return of Rankin (RoR) to prestroke baseline, FI or RoR, symptomatic intracranial hemorrhage, and mortality. Multivariable and inverse probability of treatment weighting methods were used. We explored the interaction of sex with baseline characteristics on the outcomes ordinal modified Rankin Scale and FI or RoR. RESULTS: Of 1932 patients, 1055 were women and 877 were men. Women were older (77 versus 69 years), had higher rates of atrial fibrillation, hypertension, and greater prestroke disability, but there was no difference in baseline National Institutes of Health Stroke Scale score. Inverse probability of treatment weighting analysis showed no difference between women and men in ordinal modified Rankin Scale (odds ratio, 0.98 [95% CI, 0.79–1.21]), FI or RoR (odds ratio, 0.98 [95% CI, 0.78–1.22]), severe disability or mortality (odds ratio, 0.99 [95% CI, 0.80–1.23]). The multivariable analysis of the above end points was concordant. There were no interactions between baseline characteristics and sex on the outcomes of ordinal modified Rankin Scale and FI or RoR. CONCLUSIONs: In late presenting patients with anterior circulation stroke treated with endovascular thrombectomy in the 6 to 24-hour window, there was no difference in clinical or safety outcomes between men and women.

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Section: Discussionsupporting

confidence: 89%

Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy

Abdalkader,

Ning,

Qureshi

et al. 2024

Stroke

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“…T he benefit of endovascular therapy (EVT) for patients with acute anterior circulation large vessel occlusion (LVO) with large infarct has been proven by 4 randomized clinical trials (RCTs). [1][2][3][4][5][6] The mechanical thrombectomy for large brain infarctions (MAGNA) individual patient-level data meta-analysis of 3 RCTs (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial [RESCUE-Japan LIMIT], 5 Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke [SELECT2], 4 and Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core [ANGEL-ASPECT] 3 ) presented at the European Stroke Conference (ESOC) 2023 7 and 2 other study-level meta-analyses including RCTs and observational studies 8,9 also confirmed the efficacy of EVT for such patients. However, the Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA) RCT presented at ESOC 2023 did not demonstrate that EVT was superior to medical management for such patients according to the utility-weighted modified Rankin Scale (mRS) at 90 days, falling just short of the prespecified primary outcome threshold to confirm efficacy.…”

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confidence: 99%

Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct

Sun,

Guo,

Nguyen

et al. 2024

JAMA Neurol

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ImportanceEndovascular therapy (EVT) demonstrated better outcomes compared with medical management in recent randomized clinical trials (RCTs) of patients with large infarct.ObjectiveTo compare outcomes of EVT vs medical management across different strata of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and infarct core volume in patients with large infarct.Design, Setting, and ParticipantsThis prespecified secondary analysis of subgroups of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) RCT included patients from 46 stroke centers across China between October 2, 2020, and May 18, 2022. Participants were enrolled within 24 hours of symptom onset and had ASPECTS of 3 to 5 or 0 to 2 and infarct core volume of 70 to 100 mL. Patients were divided into 3 groups: ASPECTS of 3 to 5 with infarct core volume less than 70 mL, ASPECTS of 3 to 5 with infarct core volume of 70 mL or greater, and ASPECTS of 0 to 2.InterventionsEndovascular therapy or medical management.Main Outcomes and MeasuresThe primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score.ResultsThere were 455 patients in the trial; median age was 68 years (IQR, 60-73 years), and 279 (61.3%) were male. The treatment effect did not vary significantly across the 3 baseline imaging subgroups (P = .95 for interaction). The generalized odds ratio for the shift in the 90-day mRS distribution toward better outcomes with EVT vs medical management was 1.40 (95% CI, 1.06-1.85; P = .01) in patients with ASPECTS of 3 to 5 and infarct core volume less than 70 mL, 1.22 (95% CI, 0.81-1.83; P = .23) in patients with ASPECTS of 3 to 5 and infarct core volume of 70 mL or greater, and 1.59 (95% CI, 0.89-2.86; P = .09) in patients with ASPECTS of 0 to 2.Conclusions and RelevanceIn this study, no significant interaction was found between baseline imaging status and the benefit of EVT compared with medical management in patients with large infarct core volume. However, estimates within subgroups were underpowered. A pooled analysis of large core trials stratified by ASPECTS and infarct core volume strata is warranted.Trial RegistrationClinicalTrials.gov Identifier: NCT04551664

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“…68 A study-level meta-analysis of the three randomized trials of patients with large ischemic core confirmed benefit of EVT compared with medical management with respect to a primary outcome of 90-day mRS 0 to 3, despite nonsignificantly higher rates of SICH. 69 Confirmation with other large core trials 70 and studies 71 will provide insight into its applicability in other populations and further refine identification of potential subgroups that may (or may not) benefit. [72][73][74][75] In the recently presented TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke) trial, patients with large ischemic core as defined by NCCT ASPECTS scores of 2 to 5 and acLVO were randomized to EVT versus medical management.…”

Section: Large Core Trialsmentioning

confidence: 76%

Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke: An Evolution of Trials

Starikova,

Räty,

Strbian

et al. 2023

Semin Neurol

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The last decade's progress in demonstrating the clinical benefit of endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke has transformed the paradigm of care for these patients. This review presents the milestones in implementing EVT as standard of care, demonstrates the current state of evidence, provides guidance for identifying the candidate patient for EVT, and highlights unsolved and controversial issues. Ongoing trials investigate broadening of EVT indications for patients who present with large core infarction, adjunctive intra-arterial thrombolysis, medium vessel occlusion, low NIHSS, and tandem occlusion.

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Mechanical Thrombectomy for Large Ischemic Stroke

Cited by 40 publications

References 45 publications

Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy

Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy

Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct

Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke: An Evolution of Trials

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