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https://hdl.handle.net/2440/136097
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Type: | Journal article |
Title: | Thrombectomy vs Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort |
Author: | Sarraj, A. Albers, G.W. Blasco, J. Arenillas, J.F. Ribo, M. Hassan, A.E. Pérez de la Ossa, N. Wu, T.Y.-H. Cardona Portela, P. Abraham, M.G. Chen, M. Maali, L. Kleinig, T.J. Cordato, D. Wallace, A.N. Schaafsma, J.D. Sangha, N. Gibson, D.P. Blackburn, S.L. De Lera Alfonso, M. et al. |
Citation: | Annals of Neurology, 2022; 92(3):364-378 |
Publisher: | Wiley |
Issue Date: | 2022 |
ISSN: | 0364-5134 1531-8249 |
Statement of Responsibility: | Amrou Sarraj, MD, Gregory W. Albers, MD, Jordi Blasco, MD, Juan F. Arenillas, MD, Marc Ribo, MD, Ameer E. Hassan, DO, Natalia Pérez de la Ossa, MD, Teddy Yuan, Hao Wu, MBChB, PhD, Pere Cardona Portela, MD, Michael G. Abraham, MD, Michael Chen, MD, Laith Maali, MD, Timothy J. Kleinig, MBBS, Dennis Cordato, MBBS, Adam Nathan Wallace, MD, Joanna D. Schaafsma, MD, Navdeep Sangha, MD, Daniel P. Gibson, MD, Spiros L. Blackburn, MD, Mercedes De Lera Alfonso, MD, DeepPujara, MBBS, MPH, MS, Faris Shaker, MBChB, Margy E. McCullough, Hicks, MD, Javier Luis Moreno Negrete, MD, Arturo Renu, MD, PhD, James Beharry, MBChB, Cecilia Cappelen, Smith, MBBS, Luis Rodríguez, Esparragoza, MD, Marta Olivé, Gadea, MD, Manuel Requena, MD, Tareq Almaghrabi, MD, Vitor Mendes Pereira, MD, Clark Sitton, MD, Sheryl Martin, Schild, MD, Sarah Song, MD, Henry Ma, MBBS, Leonid Churilov, PhD, Peter J. Mitchell, MBBS, Mark W. Parsons, MD, Anthony Furlan, MD, James C. Grotta, MD, Geoffrey A. Donnan, MD, Stephen M. Davis, MD, andBruce C. V. Campbell, PhD, for the PERFECT-MILD Collaborators |
Abstract: | Objective: This study was undertaken to evaluate functional and safety outcomes for endovascular thrombectomy(EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits,stratified by perfusion imaging mismatch. Methods: The pooled cohort consisted of patients with National Institutes of Health Stroke Scale (NIHSS) < 6 and internal carotid artery (ICA), M1, or M2 occlusions from the Extending the Time for Thrombolysis in Emergecy Neurological Deficits - Intra-Arterial (EXTEND-IA) Trial, Tenecteplase vs Alteplase before Endovascular Thrombectomy in Ischemic Stroke (EXTEND-IA TNK) trials Part I/II and prospective data from 15 EVT centers from October 2010 to April2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVTpri) were compared to those who received primary MM (MMpri), including those who deteriorated and received rescue EVT, in overall and propensity score (PS)-matched cohorts. Patients were stratified by target mismatch (mismatch ratio≥1.8 and mismatch volume≥15ml). Primary outcome was functional independence (90-day modified Rankin Scale=0–2). Secondary out-comes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality). Results: Of 540 patients, 286 (53%) received EVTpriand demonstrated larger critically hypoperfused tissue (Tmax> 6 seconds) volumes (median [IQR]: 64 [26–96] ml vs MMpri: 40 [14–76] ml,p< 0.001) and higher presentation NIHSS(median [IQR]: 4 [2–5] vs MMpri:3[2–4],p< 0.001). Functional independence was similar (EVTpri: 77.4% vs MMpri:75.6%, adjusted odds ratio [aOR]=1.29, 95% confidence interval [CI]=0.82–2.03,p=0.27). EVT had worse safety regarding sICH (EVTpri: 16.3% vs MMpri: 1.3%,p< 0.001) and neurological worsening (EVTpri: 19.6% vs MMpri: 6.7%,p< 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence(EVTpri: 77.4% vs MMpri: 72.7%, aOR=1.68, 95% CI=1.01–2.81,p=0.048), whereas there was a trend toward less favorable outcomes with primary EVT (EVTpri: 77.4% vs MMpri: 83.3%, aOR=0.39, 95% CI=0.12–1.34,p=0.13) with-out target mismatch (pinteraction=0.06). Similar findings were observed in a propensity score-matched subpopulation. Interpretation: Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. |
Keywords: | PERFECT-MILD Collaborators Humans Brain Ischemia Cerebral Hemorrhage Treatment Outcome Thrombectomy Prospective Studies Stroke Endovascular Procedures |
Description: | First published: 22 May 2022 |
Rights: | © 2022 American Neurological Association. |
DOI: | 10.1002/ana.26418 |
Published version: | http://dx.doi.org/10.1002/ana.26418 |
Appears in Collections: | Medicine publications |
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