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Meta-Analysis
. 2020 Jan 1;77(1):16-24.
doi: 10.1001/jamaneurol.2019.3112.

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

Nitin Goyal  1   2 , Georgios Tsivgoulis  1   3 , Konark Malhotra  4 , Muhammad F Ishfaq  1 , Abhi Pandhi  1 , Michael T Frohler  5 , Alejandro M Spiotta  6 , Mohammad Anadani  7 , Marios Psychogios  7 , Volker Maus  7 , Adnan Siddiqui  8 , Muhammad Waqas  8 , Peter D Schellinger  9 , Marcel Groen  9 , Christos Krogias  10 , Daniel Richter  10 , Maher Saqqur  11 , Pablo Garcia-Bermejo  11 , Maxim Mokin  12 , Ronen Leker  13 , Jose E Cohen  14 , Aristeidis H Katsanos  3   10 , Georgios Magoufis  15 , Klearchos Psychogios  15 , Vasileios Lioutas  16 , Meg VanNostrand  16 , Vijay K Sharma  17 , Maurizio Paciaroni  18 , Alexandros Rentzos  19 , Hazem Shoirah  20 , J Mocco  20 , Christopher Nickele  2 , Violiza Inoa  2 , Daniel Hoit  2 , Lucas Elijovich  1   2 , Andrei V Alexandrov  1 , Adam S Arthur  2
Affiliations
Meta-Analysis

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

Nitin Goyal et al. JAMA Neurol. .

Abstract

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; I2 = 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; I2 = 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Froehler reported grants from Microvention and EndoPhys; grants and personal fees from Stryker and Medtronic; personal fees from Balt; and other support from Viz.ai outside the submitted work. Dr Spiotta reported personal fees from Cerenovus and Penumbra outside the submitted work. Dr Siddiqui reported personal fees from Amnis Therapeutics, Ltd, Apama Medical, BlinkTBI Inc, Boston Scientific, Buffalo Technology Partners Inc, Canon Medical Systems USA Inc, Cerebrotech Medical Systems Inc, Cerenovus, Claret Medical, Cognition Medical, Corindus Inc, Endostream Medical Ltd, Imperative Care, Integra, International Medical Distribution Partners, Medtronic, MicroVention, Medical University of South Carolina, Neurovascular Diagnostics Inc, Northwest University, Penumbra, Q'Apel Medical LLC, Rapid Medical, Rebound Therapeutics Corp, Rist Neurovascular Inc, Serenity Medical Inc, Silk Road Medical, Spinnaker Medical Inc, StimMed, personal fees from Stryker, Synchron, Three Rivers Medical Inc, VasSol, Viseon Spine Inc, and W.L. Gore & Associates outside the submitted work. Dr Schellinger reported personal fees and other support from Boehringer Ingelheim and personal fees from Medtronic and from Expert Witness for German Courts outside the submitted work. Dr Mokin reported personal fees from Cerebrotech, Imperative Care, and Canon Medical and and other support from Serenity Medical outside the submitted work. Dr Paciaroni reported other support from Bayer, Boehringer, Pfizer, Daiichi Sankyo, Bristol Meyer Squibb, Sanofi, Medtronic, and Aspen outside the submitted work. Dr Rentzos reported personal fees from Abbott Medical Sweden and Innovation for Life (Athens, Greece) outside the submitted work. Dr Mocco reported other support from Stryker, Penumbra, Medtronic, and Microvention during the conduct of the study and personal fees from Imperative Care, Cerebrotech, Viseon, Endostream, Rebound Therapeutics, Vastrax, BlinkTBI, Serenity, NTI, Neurvana, and Cardinal Consulting outside the submitted work. Dr Nickele reported grants from Microvention outside the submitted work. Dr Hoit reported personal fees from Medtronic, Penumbra, Stryker, Siemens, Codman/Cerenovus, and Microvention outside the submitted work. Dr Elijovich reported other support from Microvention and personal fees from Cerenovus, Penumbra, Medtronic, Balt, Scientia Vascular, and Stryker outside the submitted work. Dr Arthur reported personal fees from Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Siemens, and Stryker and other support from Cerebrotech and Magneto outside the submitted work. No other disclosures were reported.

Comment in

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