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Ischemic stroke
Original research
Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria
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  1. Rohini Bhole1,
  2. Nitin Goyal1,
  3. Katherine Nearing1,
  4. Andrey Belayev1,2,
  5. Vinodh T Doss1,2,
  6. Lucas Elijovich1,2,
  7. Daniel A Hoit1,2,
  8. Georgios Tsivgoulis1,3,4,
  9. Andrei V Alexandrov1,
  10. Adam S Arthur1,2,
  11. Anne W Alexandrov1,4
  1. 1Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  2. 2Department of Neurosurgery, Semmes-Murphey Brain and Spine Institute, Memphis, Tennessee, USA
  3. 3Second Department of Neurology, ‘Attikon University Hospital’, School of Medicine, University of Athens, Athens, Greece
  4. 4Australian Catholic University, Sydney, Australia
  1. Correspondence to Dr R Bhole, University of Tennessee Health Science Center, Memphis, Department of Neurology, 855 Monroe Avenue, Suite 415, Memphis, TN 38163, USA; drrohinibhole{at}gmail.com

Abstract

Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center.

Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.

Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31–89 years, National Institutes of Health Stroke Scale (NIHSS) score 2–38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0–2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35).

Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

  • Thrombectomy
  • Stroke

https://doi.org/10.1136/neurintsurg-2015-012206

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    Footnotes

    • Contributors RB: contribution to conception of the work, data acquisition and analysis, and drafting and revising the manuscript. NG, KN, and AB: data acquisition. VTD, LE, DAH, and ASA: critical revision of the manuscript and approval of the final version. AVA and GT: substantial contribution to conception of the work, analysis and interpretation of the data, critically revising manuscript, and approval of the final version. AWA: critical revision of the manuscript for intellectual content and approval of the final version.

    • Competing interests ASA: consultant for Codman, Medtronic, Microvention, Penumbra, Sequent, Siemens, Silk Road, and Stryker; investor for Valor Medical; and research support from Codman, Penumbra, Sequent, and Siemens.

    • Ethics approval The study was approved by the institutional review board of the University of Tennessee Health Science Center.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All authors are willing to share the database with authors interested in collaborative research.