Abstract
BackgroundRandomized controlled trials (RCTs) demonstrated efficacy and safety of endovascular treatment (ET) in anterior circulation large vessel occlusions (LVO). We aimed at investigating how stroke patients treated by thrombectomy in clinical practice and their outcome compare to cohorts and results of thrombectomy trials.MethodsIn a prospective study, we consecutively included stroke patients treated by thrombectomy (2015–2017). Baseline characteristics, procedural and outcome data were analyzed. Outcome was assessed by modified Rankin Scale (mRS) at 90 days. Ordinal regression analysis was performed to identify predictors of outcome.ResultsThrombectomy was applied in 264 patients (median 75 years, 49.6% female). Median baseline National Institutes of Health Stroke Scale (NIHSS) was 16, 58.0% received concomitant intravenous thrombolysis, 62.1% were referred from external hospitals. Median Alberta Stroke Program Early CT Score (ASPECTS) was 7. Successful recanalization (modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) was achieved in 72.0%. Symptomatic intracranial hemorrhage (sICH) occurred in 4.5%. Independent outcome (mRS 0–2) was achieved in 26.2%, poor outcome (mRS 5–6) in 49.2%. Only 33.5% met the stringent enrolment criteria of previous RCTs. Lower age, baseline NIHSS, pre-stroke mRS, higher ASPECTS, and successful recanalization were independent predictors of favourable outcome.ConclusionsThe majority of stroke patients treated by ET in clinical practice would not have qualified for randomization in prior RCTs. Outcome in real-life patient cohorts is worse than in the highly selected cohorts from randomized trials, while rates of successful recanalization, sICH and outcome predictors are the same. Our findings support ET in broader patient populations than in the RCTs and may improve treatment decision in individual stroke patients with LVO in clinical practice.
Highlights
Randomized controlled trials (RCTs) demonstrated efficacy and safety of endovascular treatment (ET) in anterior circulation large vessel occlusions (LVO)
Factors taken into account for treatment decision included the elapsed time from symptom onset, stroke severity assessed by the National Institutes of Health Stroke Scale (NIHSS) on admission, site of vessel occlusion, the ASPECT score, the pre-stroke disability, and extended imaging with computed tomography (CT)-perfusion or magnetic resonance imaging (MRI) to identify potentially salvageable brain tissue, in particular, beyond 6 h of symptom onset or if the symptom onset time was uncertain
A reason for the high rate of severe complications might be rooted in the large proportion of elderly patients with preexisting comorbidities in our study population. These findings indicate, that overall outcome may be worse in stroke patients not meeting the strict criteria of randomized trials or Association/American Heart Association (ASA/AHA) guidelines, thrombectomy may as well be beneficial in these patients and less aggressive treatment may lead to a worse outcome
Summary
Randomized controlled trials (RCTs) demonstrated efficacy and safety of endovascular treatment (ET) in anterior circulation large vessel occlusions (LVO). Several randomized controlled trials (RCT) demonstrated the beneficial effect of endovascular treatment (ET) in stroke patients with an anterior circulation large vessel occlusion (LVO) [1,2,3,4,5]. These results led to a paradigm shift in acute stroke treatment, mechanical thrombectomy being standard of care for acute ischemic stroke due to LVO. There is only limited data on how patients treated by thrombectomy in clinical practice comply with the ASA/AHA-criteria, and on outcome of thrombectomy in these patients
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