Nitin Goyal1,2, Georgios Tsivgoulis1,3, Konark Malhotra4, Muhammad F Ishfaq1, Abhi Pandhi1, Michael T Frohler5, Alejandro M Spiotta6, Mohammad Anadani7, Marios Psychogios7, Volker Maus7, Adnan Siddiqui8, Muhammad Waqas8, Peter D Schellinger9, Marcel Groen9, Christos Krogias10, Daniel Richter10, Maher Saqqur11, Pablo Garcia-Bermejo11, Maxim Mokin12, Ronen Leker13, Jose E Cohen14, Aristeidis H Katsanos3,10, Georgios Magoufis15, Klearchos Psychogios15, Vasileios Lioutas16, Meg VanNostrand16, Vijay K Sharma17, Maurizio Paciaroni18, Alexandros Rentzos19, Hazem Shoirah20, J Mocco20, Christopher Nickele2, Violiza Inoa2, Daniel Hoit2, Lucas Elijovich1,2, Andrei V Alexandrov1, Adam S Arthur2. 1. Department of Neurology, University of Tennessee Health Science Center, Memphis. 2. Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis. 3. Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece. 4. Department of Neurology, West Virginia University Charleston Division, Charleston. 5. Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee. 6. Department of Neurosurgery, Medical University of South Carolina, Charleston. 7. Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany. 8. Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, New York. 9. Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany. 10. Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany. 11. Department of Neurology, Hamad General Hospital, Doha, Qatar. 12. Department of Neurosurgery, University of South Florida, Tampa. 13. Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. 14. Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. 15. Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece. 16. Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. 17. Yong Loo Lin School of Medicine, Division of Neurology, National University Hospital, National University of Singapore, Singapore. 18. Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy. 19. Department of Interventional and Diagnostic Neuroradiology, Gothenburg, Sweden. 20. Department of Neurosurgery, Mount Sinai Medical Center, New York, New York.
Abstract
Importance: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain. Objective: To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM). Data Sources: We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017. Study Selection: We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM. Main Outcomes and Measures: Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH). Results: We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P = .002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P = .02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P = .03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P = .002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P = .32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes. Conclusions and Relevance: Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial.
Importance: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain. Objective: To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM). Data Sources: We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017. Study Selection: We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM. Main Outcomes and Measures: Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH). Results: We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P = .002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P = .02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P = .03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P = .002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P = .32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes. Conclusions and Relevance: Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial.
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