The Feasibility Analysis Of Endovascular Treatment For Patients With Mild Ischemic Stroke Complicated With Anterior Circulation And Great Vessel Occlusion

Chapter One Feasibility of endovascular thrombectomy in mild ischemic stroke presenting with anterior large vessel occlusionObjectiveThere are currently no evidences by randomized controlled trials on whether mechanical thrombectomy(MT)should be performed on patients with acute mild ischemic stroke(MIS)and large vessel occlusion(LVO).The purpose of this study was to compare the clinical outcomes and safety between MT and best medical therapy(BMT)in Chinese patients presenting with MIS and LVO.MethodsFrom January 2014 to August 2017,we consecutively collected MIS patients with LVO from seven stroke centers who received MT and(or)BMT,all patients were eligible for other criteria as follows:(i)age 318 years;(ii)admission NIHSS?8;(iii)premorbid modified Rankin Score(m RS)(27)3;(iv)CT or MR angiography showing LVO in the anterior circulation(internal carotid artery,middle cerebral artery M1 or M2 segment,anterior cerebral artery and tandem occlusion).We recorded and analyzed the demographic,clinical,imaging and follow-up data from all eligible patients.The propensity-score matching method and logistic regression analysis were used to compare the functional outcomes and risk differences between MT and BMT groups in MIS and LVO patients.The primary outcome was favorable outcome(m RS:0-1)at 3 months;secondary outcomes included excellent outcome(m RS: 0-2),mortality at 3 months,and systematic intracranial hemorrhage at 48 hours.ResultsWe identified 177 eligible patients(79 in MT group and 98 in BMT group).Favorable outcome was 70.9%(56/79)in the MT group and 59.2%(58/98)in the BMT group,and excellent outcome was 58.2%(46/79)and 46.9%(46/98),respectively,which showed no statistically significance before adjustment(P=0.10 and P=0.13,respectively).The adjusted ORs of excellent outcome between MT and BMT were 3.23(95% CI:1.35 to 7.73;P=0.008)by multivariable logistic analysis,2.78(95% CI:1.12 to 6.89;P=0.02)by propensity score matching analysis(n=40 pairs),and 3.20(95% CI:1.22 to 8.37;P=0.01)by propensity score matching analysis with additional adjustments,respectively.Thrombectomy treatment did not result in excessive mortality(5.1% versus 1.0%,respectively;P(29)0.05 adjustment or not),but seemingly having higher risk of systematic intracranial hemorrhage(10.1% versus 2.0%,respectively;OR=5.40,95%CI:1.11 to 26.24;P=0.02 before adjustment).In the subgroup analysis,stroke with age(27)65(OR=6.42;95% CI: 1.51–27.24;P=0.009)and onset to treatment ?265 minutes(OR=4.66;95% CI: 1.25–17.36;P=0.018)showed the more excellent outcome in the MT group.ConclusionPatients of mild ischemic stroke(NIHSS?8)with anterior circulation large vessel occlusion,acute intravascular thrombectomy can improve 90-day clinical functional outcome,but the risk of treatment-related symptomatic intracranial hemorrhage may increase.Whether or not endovascular treatment for mild stroke still needs to be evidenced by clinical randomized controlled trials.Chapter Two Clinical outcomes of endovascular treatment beyond the time window in patients with mild ischemic strokeObjectiveEndovascular thrombectomy(EVT)has been proven to have a favorable effect on patients with acute anterior large artery occlusion(LVO),but it is limited to those patients with moderate to severe infarct,and time of onset to treatment is within the 6-hour time window(Class I,Level A).However,the benefits and risks of EVT in patients with mild ischemic stroke(MIS)and LVO when hospitalized beyond the time window are unknown.The purpose of this study was to investigate the clinical outcomes of MIS patients harboring acute proximal LVO treated by EVT within 24 hours of symptom onset.Materials and methodsBetween January 2014 and August 2017,patients with MIS(NIHSS?8)continuously visited to one of the seven stroke centers,then were confirmed having LVO by CT/MR angiography and received emergency EVT.They were divided into two groups: ?6 hours and 6–24 hours from symptom onset to groin puncture,and patients treated with 6-24 hours had an imaging mismatch based on perfusion CT or diffusion-weighted MRI.We compared the differences between the two groups in 24-hour symptom deterioration rate,the modified Rankin scale(m RS:0-1)and mortality at 90 days,symptomatic intracranial hemorrhage(s ICH)at 48 hours.Multivariable linear regression analysis was used to identify predictors for NIHSS shift after discharge.ResultsA total of 93 Chinese patients with MIS(NIHSS?8)and LVO were retrospectively collected,and 29 patients received EVT(29)6 hours after symptom onset and the remaining 64 for 6-24 hours.The overall excellent clinical outcome(m RS:0-1)ratio was 73.1%(68/93),5.4%(8/93)of mortality at 90 days,and 8.6%(5/93)of s ICH at 48 hours.There were substantial differences on hypertension history and stroke etiology between ?6 hours and 6-24 hours group(both P(27)0.05),but 24-hour symptom deterioration rate of the two groups(10.9% versus 20.7%),s ICH at 48 hours(9.4% versus 6.9%),and excellent outcomes(64.1% versus 48.2%)and mortality(6.3% versus 3.4%)at 90 days,which all showed no significant differences(all P(29)0.05).Two significant predictive factors for NIHSS shift were 48-hour s ICH(unstandardized b 7.28;95(4)CI:3.48–11.1;P(27)0.001)and baseline systolic blood pressure(unstandardized b 0.08;95(4)CI:0.03–0.14;P(28)0.005).ConclusionPatients with MIS and LAO in anterior circulation,harboring an imaging mismatch and receiving EVT within 6–24 hours after the initial symptoms,showed no heterogeneity in the efficacy and safety evaluation compared with those treated ?6 hours from symptom onset.At the same time,maintaining reasonable and stable blood pressure to avoid symptomatic intracranial hemorrhage is beneficial to the prognosis of patients.Chapter Three Endovascular treatment versus best medical treatment for patients with mild stroke and large vessel occlusion: new data and meta-analysisObjectiveEndovascular treatment(EVT)has become the standard of care for management of most large vessel occlusion(LVO)strokes.However,current clinical studies remain controversial concerning whether endovascular treatment is equally effective and safe in patients with NIHSS?8 and LVO.In this study,a meta-analysis was conducted using the published data and our new data.MethodsWe searched Pubmed,EMBASEE,Cochrane library and Clinical Trials.gov from inception to May 2018 and pooled relevant data from the studies focused on EVT versus best medical therapy(BMT),either as a standalone treatment or with intravenous tissue plasminogen activator,in patients with LVO and NIHSS?8.We used odds ratios(OR)to analyze the associations between EVT and 3-month functional outcome(assessed by the modified Rankin Scale(m RS)),mortality,and rates of symptomatic intracerebral hemorrhage in patients with mild ischemic stroke.ResultsA total of 728 patients met the meta-analysis criteria from five studies,including our study(“shang 2018”).EVT was associated with the 90-day functional independence(m RS: 0-2)in patients with mild ischemic stroke,which was significantly different from BMT(79.1% versus 70.8%;OR=1.59,95%CI: 1.11-2.28;P=0.01),but not for excellent outcome(64.2% versus 57.7%,OR=1.29,95%CI:0.94-1.77;P=0.11).And there was no differences of the mortality between the two groups(5.0% versus 6.9%;OR=0.87,95%CI: 0.45-1.69;P=0.69).However,the rate of symptomatic intracranial hemorrhage was higher in the EVT group than that in the BMT group(13.1% versus 2.5%;OR=4.12,95%CI: 2.09-8.14;P(27)0.0001).ConclusionPatients with mild ischemic stroke and LVO who underwent EVT had a significantly improved 3-month m RS score compared with those who received BMT alone.Nevertheless,EVT led to a higher risk of symptomatic intracranial hemorrhage,which was consistent with our previous findings.The efficacy of EVT in patients with LVO and mild ischemic stroke requires further confirmation in the randomized controlled trials.