Safety and efficacy of intravascular therapy in patients with progressive stroke caused by intracranial large vascular occlusion exceeding the time window of 24 hours

Endovascular therapy versus medical management for ischemic stroke presenting beyond 24 hours: Systematic review and meta-analysis

OBJECTIVE

The ideal management for ischemic stroke presenting in the very late time window, or beyond 24 hours from onset, is poorly understood. It is unknown if endovascular therapy (EVT) or best medical management (MM) is associated with superior clinical outcomes.

METHODS

A systematic literature and comparative meta-analysis was completed to evaluate the safety and efficacy of EVT vs. MM for stroke presenting beyond 24 hours. Outcome measures included: 90 day functional independence (mRS 0-2), 90 day mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. A random effects model was used for quantitative synthesis.

RESULTS

From the five included studies, a total of 704 patients were included with 461 treated with EVT and 243 treated with MM alone. The proportion of patients achieving functional independence was significantly higher in patients treated with EVT (34.6 %) compared to MM alone (15.9 %) (OR: 4.24; CI: 2.61-6.88, P < 0.00001; I2 =0 %). While sICH occurred more in EVT patients (6.8 %) compared to MM (2.8 %), this was not significant (OR: 1.96; CI: 0.61-6.27, P=0.26; I2 = 67 %). Lastly, 90 day morality occurred significantly less in the EVT group (24.5 %) compared to patients treated with MM (33.1 %), and with significantly lower odds (OR: 0.51; CI: 0.35-0.73, P=0.0003; I2=0 %).

CONCLUSIONS

In certain patients presenting beyond 24 hours with ischemic stroke, EVT is associated with a significantly higher odds of achieving functional independence and lower odds of mortality compared with MM. While these results do not function as proof, they do encourage further research into extending the window beyond 24 hours for EVT. Randomized clinical trials are warranted to validate these findings.

Is time really brain in stroke therapy?: A meta-analysis of mechanical thrombectomy up to 155 h post ictus

BACKGROUND AND OBJECTIVES

Mechanical thrombectomy (MT) has been established as the gold standard of treatment for patients with Acute Ischemic Stroke (AIS) who present up to 6 h after the onset of the stroke. Recently, the DEFUSE-3 and DAWN trials established the safety of starting the MT procedure up to 16 and 24 h after the patient was last seen well, respectively. The purpose of this study is to assess the safety and functional effects of thrombectomy in individuals with AIS detected at a late stage (> 24 h).

MATERIALS AND METHODS

PubMed, Web of Science, Embase, and Cochrane databases were thoroughly searched for research on MT in patients in the extremely late time window after AIS. The primary outcomes were symptomatic cerebral hemorrhage, 90-day mortality, Thrombolysis in Cerebral Infarction (TICI) 2b-3, and Modified Rankin Scale (mRS) 0-2.

RESULTS

Our study included fifteen studies involving a total of 1,221 patients who presented with AIS and an extended time window. The primary outcome of interest was the favorable functional outcome, mRS 0-2 at 90 days. The pooled proportion for this outcome was 45% (95% confidence interval 34-58%). Other outcomes included the TICI 2b or 3 (successful recanalization), which was reported in 12 studies and had a 79% incidence in the study population (95% CI 68-87%). Complications included: symptomatic intracranial hemorrhage (sICH), which revealed an incidence of 7% in the study population (95% CI 5-10%); and 90-day mortality, which reported a 27% incidence (95% CI 24-31%). In addition, we conducted a comparative analysis between endovascular treatment and standard medical therapy.

CONCLUSION

Our meta-analysis provides evidence that supports the need of further randomized and prospective clinical trials to better assess the effectiveness and safety of MT in these patients.

Safety and efficacy of endovascular recanalization in patients with mild anterior stroke due to large-vessel occlusion exceeding 24 hours

BACKGROUND

Endovascular recanalization (ER) has demonstrated efficacy as a treatment modality for patients presenting with acute ischemic stroke (AIS) caused by large-vessel occlusion (LVO) within a 24-hour timeframe. Nevertheless, the safety and effectiveness of ER in patients with a time of onset exceeding 24 h remain uncertain.

OBJECTIVE

To evaluate the safety and efficacy of ER treatment for mild ischemic stroke beyond 24-h from symptom onset.

METHODS

A retrospectively maintained database of mild AIS due to LVO from March2018 to September 2022 at a comprehensive stroke center was screened.Patients received ER or standard medical therapies (SMT) for anterior circulation AIS due to LVO > 24-h were selected.

RESULTS

We included 47 LVO patients with mild AIS beyond 24-h who suffered neurological deterioration (ND). 34 of these patients underwent ER, the other 13 received SMT. The technical success rate of recanalization was 82.4% (28/34). Patients received ER had significantly lower NIHSS score at discharge and 90-day mRS score (p = 0.028, p = 0.037, respectively) compared to SMT. In addition, they had significantly lower 90-day recurrence of ischemic stroke and lower incidence of moderate-severe stroke (with a NIHSS score at least 5) (p = 0.037, p = 0.033). There were 4 patients (11.7%) had perioperative complications, and no symptomatic intracranial hemorrhage occurred.

CONCLUSION

ER treatment for mild AIS due to LVO encountered ND was generally safe and effective, even beyond 24-h, and resulted in a good prognosis and lower 90-day recurrence compared to SMT.

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.

Effect of medical care linkage-continuous management mode in patients with posterior circulation cerebral infarction undergoing endovascular interventional therapy

BACKGROUND

Acute cerebral infarction is a severe type of ischemic stroke that can be divided into anterior circulation cerebral infarction and posterior circulation cerebral infarction (PCCI). PCCI affects the structure of the posterior circulation brain, because posterior part of the brain, which has more complex anatomical structures and more prone to posterior circulation vascular variation. Therefore, improving the prognosis of PCCI patients is necessary.

AIM

To explore the effect of medical care linkage-continuous management mode (MCLMM) on endovascular interventional therapy (EIT) for PCCI.

METHODS

Sixty-nine patients with PCCI who received EIT and conventional nursing intervention were selected as the control group, and 78 patients with PCCI who received EIT and MCLMM intervention were selected as the observation group. The incidence of postoperative complications, compliance and disease self-management behavior after six months of intervention, modified Rankin scale (mRS) and Barthel index (BI) scores in the acute phase and after one year of intervention, and recurrence within one year were compared between the two groups.

RESULTS

The total incidence rate of postoperative complications in the observation group (7.69%) was lower than that in the control group (18.84%) (P < 0.05). The scores for medical compliance behavior (regular medication, appropriate diet, and rehabilitation cooperation rates) and disease self-management behavior (self-will, disease knowledge, and self-care ability) in the observation group were higher than those in the control group (P < 0.05). After one year of intervention, in the observation group, the mRS score was significantly lower, and the BI score was significantly higher than those in the control group (P < 0.05). The recurrence rate within one year in the observation group (3.85%) was significantly lower than that in the control group (13.04%) (P < 0.05).

CONCLUSION

MCLMM can reduce the incidence of complications after EIT for PCCI, improve patient compliance behavior and disease self-management ability, and promote the recovery of neurological function.

Safety and Efficacy of Endovascular Treatment for Progressive Stroke in Patients With Acute Basilar Artery Occlusion

Background and Purpose: It is unknown the benefit of endovascular therapy (EVT) for progressive stroke in patients with basilar artery occlusion (BAO). The aim of this study was to compare the efficacy and safety of EVT with standard medical therapy (SMT) in a population of BAO patients with progressive stroke.

Methods: The EVT for Acute Basilar Artery Occlusion Study (BASILAR) is a national prospective registry of consecutive patients with acute BAO within 24 h of symptom onset. According to the applied therapy, all patients were divided into SMT and EVT groups. Subsequently, the EVT group was divided into early (≤6 h) and late groups (>6 h) according to the time window. The efficacy outcome was favorable functional outcomes (modified Rankin Scale score ≤ 3) at 90 days. The safety outcomes included mortality within 90 days and symptomatic intracerebral hemorrhage (sICH) after EVT.

Results: The EVT cohort presented more frequently with a favorable functional outcome (adjusted odds ratio, 5.49; 95% confidence interval, 2.06–14.61, p = 0.01) and with a decreased mortality (adjusted odds ratio, 0.3; 95% confidence interval, 0.17–0.54, p < 0.001). What's more, EVT still safe (P = 0.584, P = 0.492, respectively) and effective (P = 0.05) in patients with progressive stroke when the treatment time window exceeds 6 h.

Conclusions: EVT was more effective and safer than SMT for progressive stroke in patients with BAO. Besides, EVT remains safe and effective in patients with progressive stroke when the treatment time window exceeds 6 h. Predictors of desirable outcome in progressive stroke patients undergoing EVT included lower baseline NIHSS score, higher baseline pc-ASPECTs, successful recanalization and shorter puncture to recanalization time.