Medical Management vs Mechanical Thrombectomy for Mild Strokes An International Multicenter Study and Systematic Review and Meta-analysis

被引：104

作者：

Goyal, Nitin ^{[1
,2
]}

Tsivgoulis, Georgios ^{[1
,3
]}

Malhotra, Konark ^{[4
]}

Ishfaq, Muhammad F. ^{[1
]}

Pandhi, Abhi ^{[1
]}

Frohler, Michael T. ^{[5
]}

Spiotta, Alejandro M. ^{[6
]}

Anadani, Mohammad ^{[7
]}

Psychogios, Marios ^{[7
]}

Maus, Volker ^{[7
]}

Siddiqui, Adnan ^{[8
,9
]}

Waqas, Muhammad ^{[8
,9
]}

Schellinger, Peter D. ^{[10
]}

Groen, Marcel ^{[10
]}

Krogias, Christos ^{[11
]}

Richter, Daniel ^{[11
]}

Saqqur, Maher ^{[12
]}

Garcia-Bermejo, Pablo ^{[12
]}

Mokin, Maxim ^{[13
]}

Leker, Ronen ^{[14
]}

Cohen, Jose E. ^{[15
]}

Katsanos, Aristeidis H. ^{[3
,11
]}

Magoufis, Georgios ^{[16
]}

Psychogios, Klearchos ^{[16
]}

Lioutas, Vasileios ^{[17
]}

VanNostrand, Meg ^{[17
]}

Sharma, Vijay K. ^{[18
]}

Paciaroni, Maurizio ^{[19
]}

Rentzos, Alexandros ^{[20
]}

Shoirah, Hazem ^{[21
]}

Mocco, J. ^{[21
]}

Nickele, Christopher ^{[2
]}

Inoa, Violiza ^{[2
]}

Hoit, Daniel ^{[2
]}

Elijovich, Lucas ^{[1
,2
]}

Alexandrov, Andrei V. ^{[1
]}

Arthur, Adam S. ^{[2
]}

机构：

[1] Univ Tennessee, Hlth Sci Ctr, Dept Neurol, 847 Monroe Ave,Ste 226, Memphis, TN 38103 USA

[2] Univ Tennessee, Hlth Sci Ctr, Dept Neurosurg, Semmes Murphey Neurol & Spine Clin, Memphis, TN USA

[3] Natl & Kapodistrian Univ Athens, Attikon Univ Hosp, Dept Neurol 2, Athens, Greece

[4] West Virginia Univ, Charleston Div, Dept Neurol, Charleston, WV 25304 USA

[5] Vanderbilt Univ, Cerebrovasc Program, 221 Kirkland Hall, Nashville, TN 37235 USA

[6] Med Univ South Carolina, Dept Neurosurg, Charleston, SC 29425 USA

[7] Univ Med Ctr Gottingen, Dept Neuroradiol, Gottingen, Germany

[8] SUNY Buffalo, Dept Neurosurg, Buffalo, NY USA

[9] SUNY Buffalo, Dept Radiol, Buffalo, NY USA

[10] Univ Clin RUB, JohannesWesling Med Ctr Minden, Dept Neurol & Neurogeriatry, Minden, Germany

[11] Ruhr Univ Bochum, Dept Neurol, St Josef Hosp, Bochum, Germany

[12] Hamad Gen Hosp, Dept Neurol, Doha, Qatar

[13] Univ S Florida, Dept Neurosurg, Tampa, FL 33620 USA

[14] Hadassah Hebrew Univ, Med Ctr, Dept Neurol, Jerusalem, Israel

[15] Hadassah Hebrew Univ, Med Ctr, Dept Neurosurg, Jerusalem, Israel

[16] Metropolitan Hosp, Acute Stroke Unit, Piraeus, Greece

[17] Harvard Med Sch, Beth Israel Deaconess Med Ctr, Dept Neurol, Boston, MA 02115 USA

[18] Natl Univ Singapore, Natl Univ Hosp, Div Neurol, Yong Loo Lin Sch Med, Singapore, Singapore

[19] Univ Perugia, Div Med Cardiovasc, Perugia, Italy

[20] Dept Intervent & Diagnost Neuroradiol, Gothenburg, Sweden

[21] Mt Sinai Med Ctr, Dept Neurosurg, New York, NY 10029 USA

来源：

JAMA NEUROLOGY | 2020年 / 77卷 / 01期

关键词：

LARGE VESSEL OCCLUSION; ACUTE ISCHEMIC-STROKE; MIDDLE CEREBRAL-ARTERY; ENDOVASCULAR TREATMENT; MINIMAL SYMPTOMS; NIHSS SCORE; SCALE SCORE; OUTCOMES;

D O I：

10.1001/jamaneurol.2019.3112

中图分类号：

R74 [神经病学与精神病学];

学科分类号：

摘要：

This pooled analysis and meta-analysis assesses the outcomes of patients with mild-deficits mild emergency large-vessel occlusion treated with mechanical thrombectomy vs best medical management. Question Is mechanical thrombectomy superior to best medical management (bMM) for mild-deficits emergency large-vessel occlusion (mELVO) strokes? Findings In this pooled analysis of 251 patients with mELVO, we documented higher odds of asymptomatic intracerebral hemorrhage with mechanical thrombectomy compared with bMM. The systematic review and meta-analysis of 4 studies did not document any independent association between treatment groups and safety or efficacy outcomes. Meaning Mechanical thrombectomy has a similar efficacy and safety profile compared with bMM in patients with stroke with mELVO. 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; I-2 = 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; I-2 = 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.

引用

页码：16 / 24

页数：9

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