Introduction It remains unclear whether patients presenting with large vessel occlusion strokes and mild symptoms benefit from thrombectomy.
Objective To compare outcomes of endovascular therapy versus medical management in patients with large vessel occlusion strokes and National Institute of Health Stroke Scale (NIHSS) score ≤5.
Methods This was a retrospective analysis combining two large prospectively collected datasets including patients with (1) admission NIHSS score ≤5, (2) premorbid modified Rankin Scale (mRS) score 0–2, and (3) middle cerebral-M1/M2, intracranial carotid, anterior cerebral or basilar artery occlusions. Groups receiving (1) endovascular treatment and (2) medical management were compared. The primary and secondary outcome measures were NIHSS shift (discharge NIHSS minus admission NIHSS) and the rates of mRS 0–2 at discharge and 3–6 months, respectively. Univariate, multivariate, and matched analyses were performed.
Results Eighty-eight patients received medical management and 30 thrombectomy. Multivariable analysis indicated thrombectomy was the only predictor of favorable NIHSS shift (β −3.7, 95% CI −6.0 to −1.5, p=0.02), as well as independence at discharge (β −21.995% CI −41.4to −20.8, p<0.01) and 3–6-month follow-up (β −21.1, 95% CI −39.1 to −19.7, p<0.01). A matched analysis (based on age, baseline NIHSS and intravenous tissue plasminogen activator use) produced 26 pairs. Endovascular therapy was statistically associated with lower NIHSS at discharge (p=0.04), favorable NIHSS shift (p=0.03), and increased independence rates at discharge (p=0.03) and 3–6-month follow-up (p=0.04).
Conclusion In patients presenting with minimal stroke symptoms (NIHSS score ≤5) and large vessel occlusion strokes, mechanical thrombectomy appears to be associated with a favorable shift of NIHSS at discharge, as well as higher rates of independence at discharge and long-term follow-up. Confirmatory prospective studies are warranted.
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DCH and FOL contributed equally.
Contributors DCH: Study conception, design of the work, acquisition of data, interpretation of data, drafting of the manuscript. FOL, MB: Data acquisition, statistical analysis, critical revision of manuscript. JAG, GSS, MHL, KF, WK: Data acquisition, interpretation of data, critical revision of manuscript. MRF: Interpretation of data and critical revision of manuscript. RGN: Study conception, design of the work, critical revision of manuscript.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests DCH, FOL, MB, JAG, GSS, MHL, KF, WK, MRF. No relevant disclosures. RGN: Stryker-Neurovacular (Trevo-2&DAWN/Trial PI), Covidien (SWIFT&SWIFT-PRIME/Steering-Committee,STAR Trial/Core-Lab), Penumbra (3-D Separator Trial/Executive-Committee).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The unpublished data from this dataset is held by Grady Memorial Hospital/Emory University (DCH/RGN) as well as Massachusetts General Hospital (MHL). Requests for data sharing would be required to be discussed with them directly.