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Journal Title: | Thrombectomy versus Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort |
Authors: | Sarraj, Amrou Albers, Gregory W. Blasco, Jordi Arenillas, Juan F. Ribo, Marc Hassan, Ameer E. de la Ossa, Natalia Perez Wu, Teddy Y. Cardona Portela, Pere Abraham, Michael G. Chen, Michael Maali, Laith Kleinig, Timothy J. Cordato, Dennis Wallace, Adam Nathan Schaafsma, Joanna D. Sangha, Navdeep Gibson, Daniel P. Blackburn, Spiros L. De Lera Alfonso, Mercedes Pujara, Deep Shaker, Faris McCullough-Hicks, Margy E. Moreno Negrete, Javier Luis Renu, Arturo Beharry, James Cappelen-Smith, Cecilia Rodriguez-Esparragoza, Luis Olive-Gadea, Marta Requena, Manuel AlMaghrabi, Tareq Mendes Pereira, Vitor Sitton, Clark Martin-Schild, Sheryl Song, Sarah Ma, Henry Churilov, Leonid Mitchell, Peter J Parsons, Mark W. Furlan, Anthony Grotta, James C. Donnan, Geoffrey A. Davis, Stephen M. Campbell, Bruce C. V. Collaborators, Perfect-Mild |
Keywords: | Brain Ischemia Cerebral Hemorrhage Endovascular Procedures Humans Prospective Studies Stroke Thrombectomy Treatment Outcome |
Issue Date: | Sep-2022 |
Date Accessioned: | 2023-04-24T02:44:22Z |
Date Available: | 2023-04-24T02:44:22Z |
Accession Number: | 35599458 |
Url: | https://www.ncbi.nlm.nih.gov/pubmed/35599458 |
Description Affiliation: | Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA. Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA. Department of Neurology, Stanford University, Stanford, CA, USA. Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain. Neurology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain. Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain. Department of Neurology, Valley Baptist Medical Center, Harlingen, TX, USA. Department of Neurology, Germans Trias i Pujol University Hospital, Barcelona, Spain. Department of Neurology, Christchurch Hospital, Christchurch, New Zealand. Neurology, Bellvitge Hospital, Barcelona, Spain. Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA. Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA. Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia. Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia. Department of Neurosurgery, Ascension Wisconsin, Milwaukee, WI, USA. Neurology, Department of Internal Medicine, Toronto Western Hospital-University Health Network, Toronto, ON, Canada. Department of Neurology, Kaiser Permanente, Los Angeles, CA, USA. Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA. Department of Neurology, University of Minnesota Medical Center, Minneapolis, MN, USA. Department of Internal Medicine, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia. Department of Neurosurgery, University of Toronto, Toronto, ON, Canada. Department of Diagnostic and Interventional Radiology, University of Texas McGovern Medical School, Houston, TX, USA. Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA. Department of Neurology, Rush University Medical Center, Chicago, IL, USA. Department of Neurology, Monash University, Melbourne, Vic., Australia. Department of Biostatistics, University of Melbourne, Parkville, Vic., Australia. Department of Radiology, Royal Melbourne Hospital, Parkville, Vic., Australia. Department of Clinical Innovation and Research, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA. Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia. |
Format Startpage: | 364-378 |
Source Volume: | 92 |
Issue Number: | 3 |
Notes: | eng 2022/05/24 |
DOI: | 10.1002/ana.26418 |
Date: | 2022 |
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 April 2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVT(pri) ) were compared to those who received primary MM (MM(pri) ), 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 outcomes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality). RESULTS: Of 540 patients, 286 (53%) received EVT(pri) and demonstrated larger critically hypoperfused tissue (Tmax > 6 seconds) volumes (median [IQR]: 64 [26-96] ml vs MM(pri) : 40 [14-76] ml, p < 0.001) and higher presentation NIHSS (median [IQR]: 4 [2-5] vs MM(pri) : 3 [2-4], p < 0.001). Functional independence was similar (EVT(pri) : 77.4% vs MM(pri) : 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 (EVT(pri) : 16.3% vs MM(pri) : 1.3%, p < 0.001) and neurological worsening (EVT(pri) : 19.6% vs MM(pri) : 6.7%, p < 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence (EVT(pri) : 77.4% vs MM(pri) : 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 (EVT(pri) : 77.4% vs MM(pri) : 83.3%, aOR = 0.39, 95% CI = 0.12-1.34, p = 0.13) without target mismatch (p(interaction) = 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. ANN NEUROL 2022;92:364-378. |
URI: | https://repository.southwesthealthcare.com.au/swhealthcarejspui/handle/1/3852 |
Journal Title: | Annals of Neurology |
Type: | Journal Article |
Appears in Collections: | SWH Data Contributions |
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