Christopher Traenka1,2, Simon Jung3, Jan Gralla3,4, Rebekka Kurmann3, Christoph Stippich5, Barbara Goeggel Simonetti3,6, Henrik Gensicke1,2,7, Hubertus Mueller8, Karl Lovblad9, Ashraf Eskandari10, Francesco Puccinelli11, Jochen Vehoff12, Johannes Weber13, Susanne Wegener14, Levke Steiner14, Georg Kägi12, Andreas Luft14, Roman Sztajzel8, Urs Fischer3, Leo H Bonati1,2, Nils Peters1,2,7, Patrik Michel10, Philippe A Lyrer1,2, Marcel Arnold3, Stefan T Engelter1,2,7. 1. Department of Neurology and Stroke Center, University Hospital, University of Basel, Basel, Switzerland. 2. Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland. 3. Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland. 4. Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland. 5. Department of Neuroradiology and Stroke Center, University Hospital, University of Basel, Basel, Switzerland. 6. Neuropediatrics San Giovanni Hospital Bellinzona, Bellinzona, Switzerland. 7. Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, University of Basel, Basel, Switzerland. 8. Department of Neurology, Geneva University Hospitals, Geneva, Switzerland. 9. Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland. 10. Stroke Center, Neurology Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland. 11. Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland. 12. Department of Neurology, Kantonsspital St. Gallen, Gallen, Switzerland. 13. Division of Neuroradiology, Department of Radiology, Kantonsspital St. Gallen, Gallen, Switzerland. 14. Department of Neurology, University Hospital Zurich, Zurich, Switzerland.
Abstract
INTRODUCTION: In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications. MATERIALS AND METHODS: In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0-1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel-Haenszel model. RESULTS: Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9-11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00-14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38-2.44]) among endovascular therapy patients and intravenous thrombolysis patients. DISCUSSION AND CONCLUSION: In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which - given the limitation of our sample size - does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.
INTRODUCTION: In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications. MATERIALS AND METHODS: In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0-1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel-Haenszel model. RESULTS: Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9-11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00-14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38-2.44]) among endovascular therapy patients and intravenous thrombolysis patients. DISCUSSION AND CONCLUSION: In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which - given the limitation of our sample size - does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.
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