Evaluation of an intravenous-endovascular strategy in patients with acute proximal middle cerebral artery occlusion

Abstract

Background and purpose: IVT administered in acute ischemic stroke provides low recanalization rates in proximal intracranial occlusions, with consequently poor clinical outcome. The safety and efficacy of an IES by using mechanical thrombectomy after IVT failure were assessed in acute MCA occlusions.

Materials and methods: Patients presenting with acute MCA occlusion within 4.5 hours with an NIHSS score between 8 and 25 and a DWI ASPECTS of >5 were eligible. From September 2009 to September 2010, mechanical thrombectomy by using the Solitaire FR device was systematically performed if no clinical improvement was observed 1 hour after the initiation of IVT (IES group). Results in terms of clinical outcome were compared with those from an IVT series from January 2007 to August 2009 (IVT group).

Results: Alteplase was administered in 123 patients with proximal intracranial occlusion. Fifty-six had a confirmed MCA occlusion: 32 were included in the IVT group; and 24, in the IES group. At 24 hours, the median NIHSS improvement was 8.5 points in the IES group (25%-75% CI, 1.5-13) and 3 points in the IVT group (25%-75% CI, 1-5) (P = .001). At 3 months, 17/22 (77%) patients from the IES group and 15/30 (50%) from the IVT group had an mRS score of ≤2. After adjustment for confounding variables, IES was strongly associated with favorable clinical outcome (77% versus 50%; adjusted odds ratio = 11.9; 95% CI, 1.6-89.1; P < .02). No symptomatic intracranial hemorrhage was observed.

Conclusions: IES by using systematic mechanical thrombectomy after IVT failure safely improves the clinical outcome at 3 months and could represent an interesting alternative in the management of patients with acute MCA occlusion.

Fig. 1.

Flowchart of patients and outcome at 3 months.