Letter to the Editor Regarding “Endovascular Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke Presenting with Low National Institutes of Health Stroke Scale: Systematic Review and Meta-Analysis”

OBJECTIVE While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs. METHODS PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3–4, and posterior cerebral artery P2–4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment. RESULTS Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23–5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75–8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66–4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone. CONCLUSIONS The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

Download Full-text

SARS-CoV-2 and Stroke Characteristics

Stroke ◽

10.1161/strokeaha.120.032927 ◽

2021 ◽

Author(s):

Shima Shahjouei ◽

Georgios Tsivgoulis ◽

Ghasem Farahmand ◽

Eric Koza ◽

Ashkan Mowla ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Health Expenditure ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

National Institutes Of Health ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Lower Health

Background and Purpose: Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale. Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were <55 years of age, and 105 (24.4%) patients had no identifiable vascular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 patients) had large vessel occlusion; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median National Institutes of Health Stroke Scale (8 [3–17] versus 11 [5–17]; P =0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P <0.001) in countries with middle-to-high health expenditure when compared with countries with lower health expenditure. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%) were asymptomatic at the time of admission for SARS-CoV-2 infection. Conclusions: We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

Download Full-text

Abstract TP23: Mortality Risk in Acute Ischemic Stroke Patients With Large Vessel Occlusion Treated With Mechanical Thrombectomy: A Systematic Review and Meta-Analysis

Stroke ◽

10.1161/str.51.suppl_1.tp23 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Georgios Tsivgoulis ◽

Aristeidis H Katsanos ◽

Konark Malhotra ◽

Nitin Goyal ◽

Lina Palaiodimou ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mortality Risk ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Large Vessel ◽

Regression Analyses ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Meta Regression

Introduction: Recent randomized-controlled clinical trials (RCTs) have provided solid evidence that mechanical thrombectomy (MT) coupled with best medical therapy (BMT) improve functional outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) compared to BMT alone. However, they provided inconclusive evidence on the benefit of MT on mortality. Methods: We evaluated the association of MT+BMT compared to BMT with the risk of three-month mortality using aggregate data from all available RCTs. We also sought to identify potential predictors on the mortality risk and performed univariate meta-regression analyses. Results: Our literature search identified 11 eligible RCTs, including a total of 2,460 patients. The pooled rates of 3-month mortality were 15% (95%CI:12-19%) and 19% (95%CI:16-23%), respectively, in the MT+BMT and BMT groups. In the overall analysis MT+BMT was associated with a significantly lower risk for 3-month mortality compared to BMT (Risk Ratio=0.83, 95% confidence interval:0.69-0.99; p=0.04), without heterogeneity across included studies (I 2 =3%,p for Cochran Q=0.41). No evidence of publication bias was present in funnel plot inspection and Egger’s statistical test (p=0.762). In meta-regression analyses no moderating effect on the aforementioned association was detected with patient age (p=0.254), gender (p=0.702), admission systolic blood pressure (p=0.601), admission glucose (p=0.277), onset-to-groin puncture time (p=0.985), administration of intravenous alteplase prior to MT (p=0.804), MT under general anesthesia (p=0.735) and successful reperfusion following MT (p=0.663). Conclusion: Our meta-analysis provides evidence that MT+BMT reduce the risk of three-month mortality compared to BMT alone. This association appears not to be moderated by individual patient or procedural characteristics.

Download Full-text