Observational Study

. 2020 Dec 15;95(24):e3364-e3372.

doi: 10.1212/WNL.0000000000010955. Epub 2020 Sep 28.

Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke

Ondrej Volny¹, Charlotte Zerna², Ales Tomek¹, Michal Bar¹, Miloslav Rocek¹, Radek Padr¹, Filip Cihlar¹, Miroslava Nevsimalova¹, Lubomir Jurak¹, Roman Havlicek¹, Martin Kovar¹, Petr Sevcik¹, Vladimir Rohan¹, Jan Fiksa¹, David Cernik¹, Rene Jura¹, Daniel Vaclavik¹, Petra Cimflova¹, Josep Puig¹, Dar Dowlatshahi¹, Alexander V Khaw¹, Enrico Fainardi¹, Mohamed Najm¹, Andrew M Demchuk¹, Bijoy K Menon¹, Robert Mikulik¹, Michael D Hill¹

Affiliations

¹ From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy.
² From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy. charlotte.zerna@ucalgary.ca.

PMID: 32989100
PMCID: PMC7836655
DOI: 10.1212/WNL.0000000000010955

Observational Study

Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke

Ondrej Volny et al. Neurology. 2020.

. 2020 Dec 15;95(24):e3364-e3372.

doi: 10.1212/WNL.0000000000010955. Epub 2020 Sep 28.

Authors

Affiliations

¹ From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy.
² From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy. charlotte.zerna@ucalgary.ca.

PMID: 32989100
PMCID: PMC7836655
DOI: 10.1212/WNL.0000000000010955

Abstract

Objective: To undertake an effectiveness and safety analysis of EVT in patients with LVO and NIH Stroke Scale (NIHSS) score ≤6 using datasets of multicenter and multinational nature.

Methods: We pooled patients with anterior circulation occlusion from 3 prospective international cohorts. Patients were eligible if presentation occurred within 12 hours from last known well and baseline NIHSS ≤6. Primary outcome was modified Rankin Scale (mRS) score 0-1 at 90 days. Secondary outcomes included neurologic deterioration at 24 hours (change in NIHSS of ≥2 points), mRS 0-2 at 90 days, and 90-day all-cause mortality. We used propensity score matching to adjust for nonrandomized treatment allocation.

Results: Among 236 patients who fit inclusion criteria, 139 received EVT and 97 received medical management. Compared to medical management, the EVT group was younger (65 vs 72 years; p < 0.001), had more proximal occlusions (p < 0.001), and less frequently received concurrent IV thrombolysis (57.7% vs 71.2%; p = 0.04). After propensity score matching, clinical outcomes between the 2 groups were not significantly different. EVT patients had an 8.6% (95% confidence interval [CI] -8.8% to 26.1%) higher rate of excellent 90-day outcome, despite a 22.3% (95% CI, 3.0%-41.6%) higher risk of neurologic deterioration at 24 hours.

Conclusions: EVT for LVO in patients with low NIHSS score was associated with increased risk of neurologic deterioration at 24 hours. However, both EVT and medical management resulted in similar proportions of excellent clinical outcomes at 90 days.

Classification of evidence: This study provides Class III evidence that for patients with acute anterior circulation ischemic strokes and LVO with NIHSS < 6, EVT and medical management result in similar outcomes at 90 days.

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Figures

**Figure 1. Overlap plot of propensity scores to check for common support**

**Figure 2. Unadjusted analysis of 90-day modified Rankin Scale (mRS) score shift**
EVT = endovascular treatment; MM = medical management.

**Figure 3. Propensity score matched analysis of 90-day modified Rankin Scale (mRS) score shift**
EVT = endovascular treatment; MM = medical management.

See this image and copyright information in PMC

Comment in

Reader Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke.
Heldner MR. Heldner MR. Neurology. 2021 Sep 14;97(11):558-559. doi: 10.1212/WNL.0000000000012551. Neurology. 2021. PMID: 34518326 No abstract available.
Author Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke.
Zerna C, Volny O. Zerna C, et al. Neurology. 2021 Sep 14;97(11):559. doi: 10.1212/WNL.0000000000012550. Neurology. 2021. PMID: 34518327 No abstract available.
Reader Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke.
Malhotra A, Khunte M. Malhotra A, et al. Neurology. 2021 Sep 14;97(11):559-560. doi: 10.1212/WNL.0000000000012552. Neurology. 2021. PMID: 34518328 No abstract available.
Author Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke.
Zerna C, Volny O. Zerna C, et al. Neurology. 2021 Sep 14;97(11):560. doi: 10.1212/WNL.0000000000012553. Neurology. 2021. PMID: 34518329 No abstract available.
Author Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke.
Zerna C, Volny O. Zerna C, et al. Neurology. 2022 May 3;98(18):776. doi: 10.1212/WNL.0000000000200580. Neurology. 2022. PMID: 35501159 No abstract available.
Reader Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke.
Malhotra A, Khunte M. Malhotra A, et al. Neurology. 2022 May 3;98(18):775-776. doi: 10.1212/WNL.0000000000200579. Neurology. 2022. PMID: 35501162 No abstract available.

References

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Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke

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Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke

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