Medical and Endovascular Treatment of Patients with Large Vessel Occlusion Presenting with Mild Symptoms: An Observational Multicenter Study

Abstract

Background: A significant proportion of stroke patients presenting with mild symptoms does not have a successful recovery, especially when a large vessel is occluded. IV thrombolysis is safe and may benefit patients presenting with mild symptoms. In this study, we tested whether endovascular therapy (ET) is superior to medical therapy in these patients. Methods: Observational, prospectively collected, multicenter study of 78 consecutive patients admitted from 2009 to 2012 within 6 h of stroke, with NIHSS ≤5 at presentation or during initial diagnostic work-up and large vessel occlusion. Data for patients undergoing ET and/or IV thrombolysis were taken from the SONIIA registry of reperfusion therapies in Catalonia, or from our local stroke registry if no reperfusion therapy was delivered. We compared risk factors, clinical course, collateral circulation, revascularization rates, hemorrhagic complications, infarct volume, and the functional outcome at 3 months of patients treated with ET and those not receiving ET. Ordinal regression was used to assess the independent effect of ET on functional outcome. Results: Baseline characteristics were similar for ET (n = 34) and medically (n = 44) treated patients, except for older age in the latter. The occlusions were located in the terminal internal carotid artery (1%), M1 segment of the middle cerebral artery (33%), M2 segment (30%), posterior circulation (31%), and 5% of the patients had tandem lesions, with no significant differences between groups. Most patients in both treatment groups had good collateral flow. The rate of successful revascularization (91.2 vs. 63.4%; p = 0.006) and the risk of symptomatic intracranial hemorrhage (11.8 vs. 0%; p = 0.033) were higher in the ET group. The NIHSS scores were similar at hospital arrival, after initial neuroimaging, and at 24 h in both treatment groups and there were no significant differences in the infarct volume in a follow-up MRI. At 3 months, 35.9% of the patients had some disability. The functional outcome was similar in both treatment groups in univariate analysis and also in models adjusted for age and initial NIHSS or for variables associated to functional outcome on univariate comparison. Conversely, IV thrombolysis was associated with significantly greater chances of full recovery after adjusting for baseline differences (OR 3.70, p = 0.015). Conclusions: One third of stroke patients with mild symptoms and large vessel occlusions do not have a successful recovery. ET is effective to recanalize the occluded vessel but increases the risk of serious bleeding significantly without improving the functional outcome, and is therefore not justified routinely in these patients.

Impact of collaterals on the efficacy and safety of endovascular treatment in acute ischaemic stroke: a systematic review and meta-analysis

“…For the collateral grades being correlated with outcomes, 12 studies used the American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral flow grading system45 by digital subtraction angiography (DSA),2 9 17 18 27 31 32 37 38 42–44 mostly defining ASITN/SIR collateral grades of 3–4 and 0–2 as good and poor collaterals, respectively; 11 studies used other grading methods by DSA;12 14–16 22 25 26 33–35 39 9 studies used different grading methods on CT angiography (CTA);13 19 20 23 28 30 36 40 41 and the other studies used CT perfusion or combined grading methods with different imaging modalities 21 24 29…”

Endovascular Stroke Management: Key Elements of Success

“…Furthermore, thorough imagingbased screening is likely to identify patients with large vessel occlusions but with only mild stroke severity. A previous observational study has suggested that endovascular treatment may offer little benefit to these patients [42] . However, it is unclear what impact penumbral imaging would have on patient selection and therefore patient outcomes.…”

Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta‐analysis

“…The prescribed time windows for IVT treatment were 7 h at most, being 3 or 4.5 h in a majority of studies, whereas the time window was unknown in several primary studies. Pre-treatment collateral status was assessed by various imaging modalities, half of which were single-or multi-phase CT angiography [8,12,[20][21][22][23][24][25][26][27][28][29][30][31][32], others being CT or MR perfusion imaging [7,13,17,19,33,34], fluid-attenuated inversion recovery imaging [14,16,18,35], digital subtraction angiography [29,36], etc. Fourteen (1584 patients) of the 28 studies were included in the quantitative meta-analysis.…”