Endovascular Thrombectomy for Mild Strokes: How Low Should We Go? A Multicenter Cohort Study

被引：114

作者：

Sarraj, Amrou ^{[1
]}

Hassan, Ameer ^{[4
]}

Savitz, Sean I. ^{[1
]}

Grotta, James C. ^{[1
]}

Cai, Chunyan ^{[2
]}

Parsha, Kaushik N. ^{[1
]}

Farrell, Christine M. ^{[1
]}

Imam, Bita ^{[1
]}

Sitton, Clark W. ^{[3
]}

Reddy, Sujan T. ^{[1
]}

Kamal, Haris ^{[1
]}

Goyal, Nitin ^{[7
]}

Elijovich, Lucas ^{[7
]}

Reishus, Katelin ^{[1
]}

Krishnan, Rashi ^{[8
]}

Sangha, Navdeep ^{[5
]}

Wu, Abel ^{[5
]}

Costa, Renata ^{[6
]}

Malik, Ruqayyah ^{[6
]}

Mir, Osman ^{[10
]}

Hasan, Rashedul ^{[10
]}

Snodgrass, Lindsay M. ^{[11
]}

Requena, Manuel ^{[12
]}

Graybeal, Dion ^{[10
]}

Abraham, Michael ^{[9
]}

Chen, Michael ^{[6
]}

McCullough, Louise D. ^{[1
]}

Ribo, Marc ^{[12
]}

机构：

[1] Univ Texas Hlth Sci Ctr Houston, Dept Neurol, Houston, TX 77030 USA

[2] Univ Texas Hlth Sci Ctr Houston, Dept Internal Med, Houston, TX 77030 USA

[3] Univ Texas Hlth Sci Ctr Houston, Dept Diagnost & Intervent Imaging, Houston, TX 77030 USA

[4] Univ Texas Rio Grande Valley, Dept Intervent Neurol, Harlingen, TX USA

[5] Kaiser Permanente Los Angeles, Dept Neurol, Los Angeles, CA USA

[6] Rush Univ, Dept Neurol, Med Ctr, Chicago, IL 60612 USA

[7] Univ Tennessee, Hlth Sci Ctr, Dept Neurol & Neurosurg, Memphis, TN USA

[8] Univ Tennessee, Hlth Sci Ctr, Dept Neurol, Memphis, TN USA

[9] Kansas Univ Hosp, Dept Neurol & Radiol, Kansas City, MO USA

[10] Baylor Univ, Med Ctr, Dept Neurol, Texas A&M Univ, Dallas, TX USA

[11] Baylor Univ, Med Ctr, Dept Neurosci, Dallas, TX USA

[12] Vall dHebron Univ Hosp, Dept Neurol, Barcelona, Spain

来源：

STROKE | 2018年 / 49卷 / 10期

关键词：

brain ischemia; humans; odds ratio; Spain; thrombectomy; thrombosis; LARGE VESSEL OCCLUSION; ACUTE ISCHEMIC-STROKE; MECHANICAL THROMBECTOMY; MINIMAL SYMPTOMS; MANAGEMENT; ALTEPLASE; THERAPY;

D O I：

10.1161/STROKEAHA.118.022114

中图分类号：

R74 [神经病学与精神病学];

学科分类号：

摘要：

Background and Purpose-Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) >= 6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS, <6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods-A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS <6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results-Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance (P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions-Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS, <6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS >= 6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.

引用

页码：2398 / 2405

页数：8

共 20 条

[1] Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging [J].

Albers, G. W. ;

Marks, M. P. ;

Kemp, S. ;

Christensen, S. ;

Tsai, J. P. ;

Ortega-Gutierrez, S. ;

McTaggart, R. A. ;

Torbey, M. T. ;

Kim-Tenser, M. ;

Leslie-Mazwi, T. ;

Sarraj, A. ;

Kasner, S. E. ;

Ansari, S. A. ;

Yeatts, S. D. ;

Hamilton, S. ;

Mlynash, M. ;

Heit, J. J. ;

Zaharchuk, G. ;

Kim, S. ;

Carrozzella, J. ;

Palesch, Y. Y. ;

Demchuk, A. M. ;

Bammer, R. ;

Lavori, P. W. ;

Broderick, J. P. ;

Lansberg, M. G. .

NEW ENGLAND JOURNAL OF MEDICINE, 2018, 378 (08) :708-718

[2] Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy [J].

Barber, PA ;

Demchuk, AM ;

Zhang, JJ ;

Buchan, AM .

LANCET, 2000, 355 (9216) :1670-1674

[3] A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke [J].

Berkhemer, O. A. ;

Fransen, P. S. S. ;

Beumer, D. ;

van den Berg, L. A. ;

Lingsma, H. F. ;

Yoo, A. J. ;

Schonewille, W. J. ;

Vos, J. A. ;

Nederkoorn, P. J. ;

Wermer, M. J. H. ;

van Walderveen, M. A. A. ;

Staals, J. ;

Hofmeijer, J. ;

van Oostayen, J. A. ;

Nijeholt, G. J. Lycklama A. ;

Boiten, J. ;

Brouwer, P. A. ;

Emmer, B. J. ;

de Bruijn, S. F. ;

van Dijk, L. C. ;

Kappelle, L. J. ;

Lo, R. H. ;

Van Dijk, E. J. ;

de Vries, J. ;

de Kort, P. L. M. ;

van Rooij, W. J. J. ;

van den Berg, J. S. P. ;

van Hasselt, B. A. A. M. ;

Aerden, L. A. M. ;

Dallinga, R. J. ;

Visser, M. C. ;

Bot, J. C. J. ;

Vroomen, P. C. ;

Eshghi, O. ;

Schreuder, T. H. C. M. L. ;

Heijboer, R. J. J. ;

Keizer, K. ;

Tielbeek, A. V. ;

den Hertog, H. M. ;

Gerrits, D. G. ;

van den Berg-Vos, R. M. ;

Karas, G. B. ;

Steyerberg, E. W. ;

Flach, H. Z. ;

Marquering, H. A. ;

Sprengers, M. E. S. ;

Jenniskens, S. F. M. ;

Beenen, L. F. M. ;

van den Berg, R. ;

Koudstaal, P. J. .

NEW ENGLAND JOURNAL OF MEDICINE, 2015, 372 (01) :11-20

[4] Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial [J].

Bracard, Serge ;

Ducrocq, Xavier ;

Mas, Jean Louis ;

Soudant, Marc ;

Oppenheim, Catherine ;

Moulin, Thieriy ;

Guillemin, Francis .

LANCET NEUROLOGY, 2016, 15 (11) :1138-1147

[5] Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection [J].

Campbell, B. C. V. ;

Mitchell, P. J. ;

Kleinig, T. J. ;

Dewey, H. M. ;

Churilov, L. ;

Yassi, N. ;

Yan, B. ;

Dowling, R. J. ;

Parsons, M. W. ;

Oxley, T. J. ;

Wu, T. Y. ;

Brooks, M. ;

Simpson, M. A. ;

Miteff, F. ;

Levi, C. R. ;

Krause, M. ;

Harrington, T. J. ;

Faulder, K. C. ;

Steinfort, B. S. ;

Priglinger, M. ;

Ang, T. ;

Scroop, R. ;

Barber, P. A. ;

McGuinness, B. ;

Wijeratne, T. ;

Phan, T. G. ;

Chong, W. ;

Chandra, R. V. ;

Bladin, C. F. ;

Badve, M. ;

Rice, H. ;

de Villiers, L. ;

Ma, H. ;

Desmond, P. M. ;

Donnan, G. A. ;

Davis, S. M. .

NEW ENGLAND JOURNAL OF MEDICINE, 2015, 372 (11) :1009-1018

[6] Mechanical Thrombectomy for Minor and Mild Stroke Patients Harboring Large Vessel Occlusion in the Anterior Circulation A Multicenter Cohort Study [J].

Dargazanli, Cyril ;

Arquizan, Caroline ;

Gory, Benjamin ;

Consoli, Arturo ;

Labreuche, Julien ;

Redjem, Hocine ;

Eker, Omer ;

Decroix, Jean-Pierre ;

Corlobe, Astrid ;

Mourand, Isabelle ;

Gaillard, Nicolas ;

Ayrignac, Xavier ;

Charif, Mahmoud ;

Duhamel, Alain ;

Labeyrie, Paul-Emile ;

Riquelme, Carlos ;

Ciccio, Gabriele ;

Smajda, Stanislas ;

Desilles, Jean-Philippe ;

Gascou, Gregory ;

Lefevre, Pierre-Henri ;

Mantilla-Garcia, Daniel ;

Cagnazzo, Federico ;

Coskun, Oguzhan ;

Mazighi, Mikael ;

Riva, Roberto ;

Bourdain, Frederic ;

Labauge, Pierre ;

Rodesch, Georges ;

Obadia, Michael ;

Bonafe, Alain ;

Turjman, Francis ;

Costalat, Vincent ;

Piotin, Michel ;

Blanc, Raphael ;

Lapergue, Bertrand .

STROKE, 2017, 48 (12) :3274-3281

[7] Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation (vol 43, pg 305, 2017) [J].

Dargazanli, Cyril ;

Consoli, Arturo ;

Gory, Benjamin ;

Blanc, Raphael ;

Labreuche, Julien ;

Preda, Cristian ;

Bourdain, Frederic ;

Decroix, Jean-Pierre ;

Redjem, Hocine ;

Ciccio, Gabriele ;

Mazighi, Mikael ;

Smajda, Stanislas ;

Desilles, Jean-Philippe ;

Riva, Roberto ;

Labeyrie, Paul-Emile ;

Coskun, Oguzhan ;

Rodesch, Georges ;

Turjman, Francis ;

Piotin, Michel ;

Lapergue, Bertrand .

CEREBROVASCULAR DISEASES, 2017, 43 (5-6) :313-313

[8] Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke [J].

Goyal, M. ;

Demchuk, A. M. ;

Menon, B. K. ;

Eesa, M. ;

Rempel, J. L. ;

Thornton, J. ;

Roy, D. ;

Jovin, T. G. ;

Willinsky, R. A. ;

Sapkota, B. L. ;

Dowlatshahi, D. ;

Frei, D. F. ;

Kamal, N. R. ;

Montanera, W. J. ;

Poppe, A. Y. ;

Ryckborst, K. J. ;

Silver, F. L. ;

Shuaib, A. ;

Tampieri, D. ;

Williams, D. ;

Bang, O. Y. ;

Baxter, B. W. ;

Burns, P. A. ;

Choe, H. ;

Heo, J. -H. ;

Holmstedt, C. A. ;

Jankowitz, B. ;

Kelly, M. ;

Linares, G. ;

Mandzia, J. L. ;

Shankar, J. ;

Sohn, S. -I. ;

Swartz, R. H. ;

Barber, P. A. ;

Coutts, S. B. ;

Smith, E. E. ;

Morrish, W. F. ;

Weill, A. ;

Subramaniam, S. ;

Mitha, A. P. ;

Wong, J. H. ;

Lowerison, M. W. ;

Sajobi, T. T. ;

Hill, M. D. .

NEW ENGLAND JOURNAL OF MEDICINE, 2015, 372 (11) :1019-1030

[9] Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials [J].

Goyal, Mayank ;

Menon, Bijoy K. ;

van Zwam, Wim H. ;

Dippel, Diederik W. J. ;

Mitchell, Peter J. ;

Demchuk, Andrew M. ;

Davalos, Antoni ;

Majoie, Charles B. L. M. ;

van der Lugt, Aad ;

de Miquel, Maria A. ;

Donnan, Geoff Rey A. ;

Roos, Yvo B. W. E. M. ;

Bonafe, Alain ;

Jahan, Reza ;

Diener, Hans-Christoph ;

van den Berg, Lucie A. ;

Levy, Elad I. ;

Berkhemer, Olvert A. ;

Pereira, Vitor M. ;

Rempel, Jeremy ;

Millan, Monica ;

Davis, Stephen M. ;

Roy, Daniel ;

Thornton, John ;

San Roman, Luis ;

Ribo, Marc ;

Beumer, Debbie ;

Stouch, Bruce ;

Brown, Scott ;

Campbell, Bruce C. V. ;

van Oostenbrugge, Robert J. ;

Saver, Jeff Rey L. ;

Hill, Michael D. ;

Jovin, Tudor G. .

LANCET, 2016, 387 (10029) :1723-1731

[10] Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts [J].

Haussen, Diogo C. ;

Lima, Fabricio O. ;

Bouslama, Mehdi ;

Grossberg, Jonathan A. ;

Silva, Gisele S. ;

Lev, Michael H. ;

Furie, Karen ;

Koroshetz, Walter ;

Frankel, Michael R. ;

Nogueira, Raul G. .

JOURNAL OF NEUROINTERVENTIONAL SURGERY, 2018, 10 (04) :325-329

← 1 2 →