Distal arterial occlusions in patients with mild strokes – is endovascular therapy superior to thrombolysis alone?

A comparison of endovascular therapy and medical management in patients with large vessel occlusion mild stroke treated between 2015 and 2023: a systematic review and meta-analysis

OBJECTIVE

Endovascular therapy (EVT) is recommended for patients with acute large-vessel occlusion (LVO) However, its efficacy and safety compared to medical management (MM) in patients with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 remains unclear. This meta-analysis compared EVT with medical MM in patients with large vessel occlusion mild stroke treated between 2015 and 2023, following the publication of the first randomized controlled trial.

MATERIALS AND METHODS

Biomedical database searches (inception to March 21, 2023) retrieved articles reporting favorable functional outcome(modified Rankin Scale [mRS] 0-1) and functional independence (mRS 0-2), 90-day mortality and symptomatic intracranial hemorrhage (sICH). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) to maintain methodological rigor and transparency in our meta-analysis.

RESULTS

We conducted a meta-analysis of 22 studies (4,985 patients) to reveal no significant differences in favorable functional outcomes and independence across all groups. However, in patients treated between 2015 and 2023, EVT exhibited a higher risk of 90-day mortality (Odds Ratio [OR] = 1.84, 95% Confidence Interval [CI] [1.10, 3.07], p = 0.02) and sICH (OR = 3.36, 95% CI [1.96, 6.66], p < 0.01). EVT correlated with elevated sICH in the anterior circulation (OR=2.94, 95%CI [1.82, 4.74], p<0.01) regardless of the proximal (OR=2.20, 95%CI [1.04, 4.69], p=0.04) or distal (OR=3.44, 95%CI [1.43, 8.32], p<0.01) location of the occlusion. EVT correlated with elevated sICH rates in patients treated within 6 hours of symptom onset or those with NHISS≤5.

CONCLUSION

In patients treated between 2015 and 2023, EVT and MM did not differ in efficacy in acute LVO mild stroke; MM associated with better safety outcomes. Rigorous randomized controlled trials are warranted.

Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke

Introduction

In the absence of clinical trials, the benefit of endovascular therapy (EVT) on the treatment of acute ischemic stroke (AIS) with primary distal and medium vessel occlusions (DMVO) is still not well defined. The aim of the study is to evaluate EVT with or without intravenous thrombolysis (EVT ± IVT) in primary DMVO stroke in comparison with a control cohort treated with IVT alone.

Methods

We analysed all consecutive AIS with proven primary DMVO. Primary endpoints were excellent outcome, functional independence at 3 months follow-up, and early neurologic improvement at 1 day after treatment.

Results

One hundred and fourteen patients with DMVO strokes were included between 2019 and 2023. Propensity-weighted analysis showed no significant differences in EVT ± IVT vs IVT for the excellent outcome (adjusted OR [aOR], 1.575; 95% CI, 0.706-3.513), functional independence (aOR, 2.024; 95% CI, 0.845-4.848), early neurological improvement (aOR, 2.218; 95% CI, 0.937-5.247), mortality (aOR, 0.498; 95% CI, 0.177-1.406), symptomatic intracranial haemorrhage (aOR, 0.493; 95% CI, 0.102-2.385), and subarachnoid haemorrhage (aOR, 0.560; 95% CI, 0.143-2.187). The type of revascularization did not influence the percentage of cerebral volume lost (adjusted linear regression estimate, -19.171, t value, 11.562; p = 0.104).

Conclusions

This study supports the hypothesis that patients with primary DMVO stroke treated with EVT (±IVT) or IVT alone have comparable outcomes.

EnDovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for MedIum distal VeSsel Occlusion sTroke (DISTAL): An international, multicentre, randomized-controlled, two-arm, assessor-blinded trial

RATIONALE

Whether endovascular therapy (EVT) in addition to best medical treatment (BMT) in people with acute ischemic stroke (AIS) due to a medium distal vessel occlusion (MDVO) is beneficial remains unclear.

AIM

To determine if people experiencing an AIS due to an isolated MDVO (defined as the co- or non-dominant M2 segment, the M3 or M4 segment of the middle cerebral artery, the A1, A2, or A3 segment of the anterior cerebral artery or the P1, P2 or P3 segment of the posterior cerebral artery) will have superior outcome if treated with EVT in addition to BMT compared to BMT alone.

SAMPLE SIZE

To randomize 526 participants 1:1 to EVT plus BMT or BMT alone.

METHODS AND DESIGN

A multicentre, international, prospective, randomized, open-label, blinded-endpoint (PROBE) superiority trial.

OUTCOMES

The primary efficacy endpoint is the distribution of disability levels on the modified Rankin Scale at 90 days. Secondary clinical efficacy outcomes include normalized change in National Institutes of Health Stroke Scale score from baseline to day 1, cognitive outcome at 90 days, and health-related quality of life at 90 days. Safety outcomes include all serious adverse events, symptomatic intracranial hemorrhage within 24 h, and all-cause mortality up to 90 days. Secondary imaging outcomes include successful reperfusion at end of EVT procedure and recanalization of target artery at 24 h.

DISCUSSION

DISTAL will inform physicians whether EVT in addition to BMT in people with AIS due to a MDVO is more efficacious than BMT alone.

Endovascular therapy for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis

AIMS

Endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is a potential frontier of acute ischemic stroke (AIS) treatment, but its efficacy against best medical therapy (BMT) remains unknown. We performed a systematic review and meta-analysis evaluating the efficacy and safety of EVT versus BMT in primary DMVO.

METHODS

We systematically searched PubMed, Cochrane Library and Embase, from inception to August 14, 2022, for studies comparing EVT with BMT in DMVO-AIS. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (90-day modified Rankin Scale (mRS) 0-2) and excellent functional outcomes (90-day mRS 0-1). Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality.

RESULTS

Fourteen observational and two randomized-controlled studies were included, with 1202 patients receiving EVT and 1267 receiving BMT. After trim-and-fill correction, EVT achieved significantly better odds of functional independence than BMT (adjusted OR 1.61, 95% CI 1.06 to 2.43). There were no significant differences in overall excellent functional outcomes (OR 1.23, 95% CI 0.88 to 1.71), sICH (OR 1.44, 95% CI 0.78 to 2.66), and mortality (OR 1.03, 95% CI 0.73 to 1.45). Stratified by EVT method, mechanical thrombectomy±intra-arterial thrombolysis achieved more excellent functional outcomes than BMT (OR 1.59, 95% CI 1.13 to 2.23). In mild strokes (National Institutes of Health Stroke Scale score <6), EVT caused significantly more sICH (OR 6.30, 95% CI 1.55 to 25.64).

CONCLUSIONS

EVT shows promising efficacy benefit over BMT for primary DMVO-AIS. Further randomized controlled trials are necessary to evaluate the efficacy and safety of EVT in DMVO-AIS.

Endovascular therapy versus medical management for mild strokes due to medium and distal vessel occlusions

BACKGROUND

Distal and medium vessel occlusion (DMVO) strokes account for up to 40% of all acute ischemic strokes, many of which have a low initial deficit severity. Increasingly, endovascular treatment (EVT) is considered for these patients. However, there is a paucity of data comparing potential safety and efficacy of EVT versus best medical management (BMT) in these patients, particularly when presenting with mild symptoms.

METHODS

We retrospectively analyzed consecutive DMVO patients with NIHSS ≤6 who presented between January 2018 and December 2021 within 24 h from last seen well. We compared early and late clinical outcomes, as well as safety outcomes using multivariable linear and logistic regression analyses to determine whether EVT was independently associated with the outcomes of interest.

RESULTS

We included 80 subjects that fulfilled our study criteria (n = 41 BMT and n = 39 EVT). On adjusted analyses, when comparing EVT and BMT groups, there was no statistical difference in the NIHSS at discharge (Coefficient = -0.6, 95%-CI = -3.45-2.26, p = 0.678) or in the modified Rankin scale (mRS) at discharge (Coefficient = 0.37, 95%-CI = -0.52-1.25, p = 0.408). Furthermore, there was no difference in the 3-month mRS defined as good (mRS 0-2) (OR = 0.56, 95%-CI = 0.17-1.83, p = 0.341) or excellent (mRS 0-1) (OR = 0.45, 95%-CI = 0.15-1.34, p = 0.152). Finally, there was no difference in the incidence of all-type parenchymal hemorrhage (OR = 0.9, 95%-CI = 0.22-3.62, p = 0.879).

CONCLUSIONS

We found that among DMVO patients with low admission NIHSS treatment with EVT versus BMT was associated with similar outcomes. Larger prospective studies are required to confirm these findings.

Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis

Background

Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results.

Methods

We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis.

Results

6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively).

Conclusions

No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.

Mechanical Thrombectomy for Mild Acute Ischemic Stroke with Large-Vessel Occlusion: A Systematic Review and Meta-Analysis

BACKGROUND

The functional prognosis of mechanical thrombectomy (MT) for mild acute ischemic stroke (AIS) with large-vessel occlusion (LVO) is controversial. To explore a more precise estimation, a meta-analysis was conducted.

METHODS

The relevant studies were identified by searching PubMed, Embase, Web of Science, and Cochrane Collaboration Database until October 2021. The pooled analysis, subgroup analysis, sensitivity analysis, and publication bias examination were all conducted. The meta-analysis was performed by using Stata 12.0.

RESULTS

Eleven studies were included with a total of 1,929 subjects, including 794 patients receiving MT and 1,135 patients receiving medical management. The pooled analysis showed that MT might be not associated with functional prognosis among mild AIS with LVO (excellent functional prognosis: risk ratio (RR) = 1.07, 95% confidence interval (CI) = 0.94-1.21, p = 0.294; favorable functional prognosis: RR = 1.01, 95% CI = 0.96-1.06, p = 0.823). The statistical stability and reliability were demonstrated by the sensitivity analysis and publication bias outcomes.

CONCLUSION

Our meta-analysis suggests that MT may be not associated with functional prognosis of mild AIS with LVO.

Hemorrhagic stroke outcomes of KApSR patients with co-morbid diabetes and Alzheimer's disease

Background

Vascular risk factors, such as diabetes mellitus (DM), are associated with poorer outcomes following many neurodegenerative diseases, including hemorrhagic stroke and Alzheimer's disease (AD). Combined AD and DM co-morbidities are associated with an increased risk of hemorrhagic stroke and increased Medicare costs. Therefore, we hypothesized that patients with DM in combination with AD, termed DM/AD, would have increased hemorrhagic stroke severity.

Methods

Kentucky Appalachian Stroke Registry (KApSR) is a database of demographic and clinical data from patients that live in Appalachia, a distinct region with increased health disparities and stroke severity. Inpatients with a primary indication of hemorrhagic stroke were selected from KApSR for retrospective analysis and were separated into four groups: DM only, AD only, neither, or both.

Results

Hemorrhagic stroke patients (2,071 total) presented with either intracerebral hemorrhage (ICH), n=1,448, or subarachnoid hemorrhage (SAH), n=623. When examining all four groups, subjects with AD were significantly older (AD+, 80.9±6.6 yrs) (DM+/AD+, 77.4±10.0 yrs) than non AD subjects (DM-/AD-, 61.3±16.5 yrs) and (DM+, 66.0±12.5 yrs). A higher percentage of females were among the AD+ group and a higher percentage of males among the DM+/AD+ group. Interestingly, after adjusting for multiple comparison, DM+/AD+ subjects were ten times as likely to suffer a moderate to severe stroke based on a National Institute of Health Stroke (NIHSS) upon admission [odds ratio (95% CI)] compared to DM-/AD- [0.1 (0.02-0.55)], DM+ [0.11 (0.02-0.59)], and AD+ [0.09(0.01-0.63)]. The odds of DM+/AD+ subjects having an unfavorable discharge destination (death, hospice, long-term care) was significant (P<0.05) from DM-/AD- [0.26 (0.07-0.96)] when adjusting for sex, age, and comorbidities.

Conclusions

In our retrospective analysis utilizing KApSR, regardless of adjusting for age, sex, and comorbidities, DM+/AD+ patients were significantly more likely to have had a moderate or severe stroke leading to an unfavorable outcome following hemorrhagic stroke.

Endovascular Thrombectomy VS. Medical Treatment for Mild Stroke Patients: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

At present, endovascular thrombectomy (EVT) has been gradually became a standard therapy for stroke patients caused by emergent large-vessel occlusion (ELVO). However, the question about whether EVT is superior to medical treatment for mild stroke patients presenting with a low baseline National Institutes of Health Stroke Scale (NIHSS) score remains unclear. The aim of this systematic review and meta-analysis was to compare the safety and efficacy of EVT with medical treatment in mild stroke patients.

MATERIAL AND METHODS

A systematic review and meta-analysis was conducted through searching the PubMed, Embase and Cochrane Library databases. All statistical analyses were performed by using Review Manager 5.3 software. Primary outcomes of this meta-analysis were as follows: favorable functional outcome at 90 days (defined as a modified Rankin scale (mRS) score of 0-2); excellent functional outcome at 90 days (defined as a mRS score of 0-1); symptomatic intracerebral hemorrhage (sICH); mortality at 90 days.

RESULTS

A total of 13 eligible studies with 2135 patients were included in this meta-analysis. The pooled results indicated that mild stroke patients underwent EVT had higher risk of sICH than those receiving medical treatment alone (OR = 3.21; 95% CI, 1.98-5.22; P < 0.001). In addition, no significant difference was found between the two groups in mortality at 90 days (OR = 1.80; 95% CI, 0.88-3.65; P=0.11). Meanwhile, no significant difference was found between the two groups in patients achieving favorable functional outcome at 90 days and excellent functional outcome at 90 days (OR = 1.10; 95% CI, 0.74-1.64; P = 0.65) (OR = 1.03; 95% CI, 0.79-1.35; P = 0.80).

CONCLUSIONS

Our pooled results showed similar clinical outcomes at 90 days of EVT and medical treatment in mild stroke patients with ELVO, although patients underwent EVT had higher rates of sICH. However, due to several limitations of this meta-analysis, randomized controlled trials are needed to further evaluate the potential efficacy of EVT in mild stroke patients.