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Qin B, Zhang Y, Liang S, Liang H, Tang S, Liang Z. Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:e475-e483. [PMID: 36813553 DOI: 10.1136/jnis-2022-019959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown. OBJECTIVE To conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO. METHODS EMBASE, Cochrane Library, PubMed, and Clinicaltrials.gov databases were searched until October 2022. Both retrospective and prospective studies which compared the clinical outcomes between EVT and medical treatment were included. ORs and 95% confidence intervals (CIs) for excellent and favorable functional outcomes, symptomatic intracranial hemorrhage (ICH), and mortality were pooled using a random-effects model. A propensity score (PS)-based methods adjusted analysis was also performed. RESULTS 4335 patients from 14 studies were included. In patients with mild stroke and AACLVO, EVT presented no marked differences in excellent and favorable functional outcomes and mortality compared with medical treatment. A higher risk of symptomatic ICH (OR=2.79; 95% CI 1.49 to 5.24; P=0.001) was observed with EVT. Subgroup analysis revealed that EVT had potential benefit for proximal occlusions with excellent functional outcomes (OR=1.68; 95% CI 1.01 to 2.82; P=0.05). Similar results were observed when PS-based methods adjusted analysis was used. CONCLUSION EVT did not significantly benefit clinical functional outcomes in comparison with medical treatment in patients with mild stroke and AACLVO. However, it may improve functional outcomes when treating patients with proximal occlusion, despite being associated with an increased risk of symptomatic ICH. Stronger evidence from ongoing randomized controlled trials is required.
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Affiliation(s)
- Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yunli Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shiting Tang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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Lin CH, Saver JL, Ovbiagele B, Tang SC, Lee M, Liebeskind DS. Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis. J Neurointerv Surg 2023; 15:350-354. [PMID: 35292565 PMCID: PMC10086511 DOI: 10.1136/neurintsurg-2022-018662] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions. METHODS We searched PubMed, Embase, the Cochrane Library, and clinicaltrials.gov from January 2000 to September 2021 to identify studies comparing EVT versus best medical management (BMM) in AIS with National Institutes of Health Stroke Scale (NIHSS) scores ≤5 due to proximal internal carotid artery (ICA) or M1 versus distal M2 occlusions. We included studies that reported the number of patients with proximal or distal occlusions separately and reported the number of patients with freedom of disability (modified Rankin Scale (mRS) score 0-1) or functional independence (mRS score 0-2) at 90 days in proximal or M2 occlusions, respectively. OR with 95% CI was used. RESULTS We identified six studies with 653 proximal ICA and M1 occlusion patients and 666 distal M2 occlusion patients. Pooled results showed EVT versus BMM was associated with a higher rate of being disability-free in patients with proximal occlusions (OR 1.58, 95% CI 1.09 to 2.30), but was associated with a lower rate of being disability-free in patients with M2 occlusions (OR 0.70, 95% CI 0.49 to 0.99). Effect of EVT in proximal versus distal occlusions was substantially different (P for interaction=0.002). A similar pattern was seen for functional independence (P for interaction=0.05). CONCLUSIONS For patients with mild AIS, observational data suggest that EVT may be beneficial for proximal ICA or M1 but not for distal M2 occlusions. Randomized trials are needed to confirm these findings. PROSPERO REGISTRATION NUMBER CRD42021281034.
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Affiliation(s)
- Chun-Hsien Lin
- Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L Saver
- Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Bruce Ovbiagele
- University of California San Francisco, San Francisco, California, USA
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng Lee
- Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - David S Liebeskind
- Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
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Sarraj A, Pujara D, Campbell BC. Response to letter by Hsia et al, titled "Advanced imaging for mild stroke patients - selection for acute interventions". Ann Neurol 2022; 92:905. [PMID: 35996896 DOI: 10.1002/ana.26491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/20/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Amrou Sarraj
- University Hospitals Cleveland Medical Center, Neurology, Stroke, OH, USA.,Case Western Reserve University School of Medicine, Neurology, OH, USA
| | - Deep Pujara
- University Hospitals Cleveland Medical Center, Neurology, Stroke, OH, USA
| | - Bruce Cv Campbell
- The Royal Melbourne Hospital, Neurology, Melbourne, VIC, Australia.,Melbourne Brain Centre, Melbourne, VIC, Australia
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Sun D, Huo X, Raynald, Wang A, Mo D, Gao F, Ma N, Miao Z. Intra-Arterial Thrombolysis Vs. Mechanical Thrombectomy in Acute Minor Ischemic Stroke Due to Large Vessel Occlusion. Front Neurol 2022; 13:860987. [PMID: 35903125 PMCID: PMC9315389 DOI: 10.3389/fneur.2022.860987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background The efficacy and safety of mechanical thrombectomy (MT) in acute large vessel occlusion (LVO) patients with minor stroke (NIHSS ≤ 5) remains undetermined. We aimed to compare the efficacy and safety of intra-arterial thrombolysis (IAT) alone vs. MT for LVO patients with minor stroke. Methods Patients were selected from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry, a prospective multicenter registry study, and divided into MT and IAT alone groups. We compared the outcome measures between the two groups, including 90-day functional outcome evaluated by the modified Rankin Scale (mRS), the final recanalization level, intracranial hemorrhage, and mortality within 90-days by logistic regression models with adjustment. Besides the conventional multivariable analysis, we performed a sensitivity analysis by adjusting the propensity score to confirm our results. The propensity score was derived using a logistic regression model. Results Of the 120 patients, 63 received IAT alone and 57 received MT as the first-line treatment strategy. As compared to MT group, patients in the IAT alone group were associated with a higher chance of 90-day mRS 0-2 [93.7% vs. 71.9%, odds ratio (OR) = 4.75, 95% confidence interval (CI): 1.20–18.80, P = 0.027], a high chance of 90-day mRS 0-3 (96.8% vs. 86.7%, OR = 11.35, 95% CI: 1.93–66.86, P = 0.007), a shorter median time from puncture to recanalization (PTR) (60 min vs. 100 min, β = −63.70, 95% CI: −81.79– −45.61, P < 0.001), a lower chance of any intracranial hemorrhage (ICH) within 48 h (3.2% vs. 19.3%, OR = 0.15, 95% CI: 0.03–0.79, P = 0.025), and a lower chance of mortablity within 90 days (1.6% vs. 9.2%, OR = 0.05, 95% CI: 0.01–0.57, P = 0.016). Similarly, the sensitivity analysis showed the robustness of the primary analysis. Conclusions Compared with MT, IAT may improve 90-day clinical outcomes with decreased ICH rate and mortality in LVO patients with minor stroke.
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Hou X, Feng X, Wang H, Li Q. Mechanical Thrombectomy for Mild Acute Ischemic Stroke with Large-Vessel Occlusion: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2022; 51:615-622. [PMID: 35378529 DOI: 10.1159/000523838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/03/2022] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Xiaowen Hou
- School of Public Health, Shenyang Medical College, Shenyang, China
| | - Xu Feng
- School of Public Health, Shenyang Medical College, Shenyang, China
| | - Huixin Wang
- School of Public Health, Shenyang Medical College, Shenyang, China
| | - Qian Li
- School of Public Health, Shenyang Medical College, Shenyang, China
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Affiliation(s)
- Joseph P Broderick
- Department of Neurology, University of Cincinnati Gairdner Neuroscience Institute, University of Cincinnati Academic Health Center, OH (J.P.H.)
| | - Michael D Hill
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Alberta, Canada (M.D.H.)
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