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Abstract
Background Clinical data on endovascular thrombectomy (EVT) for anterior cerebral artery (ACA) stroke is limited, and there are no established patient selection criteria for treatment.
Methods BEACON (Best medical management versus Endovascular thrombectomy for Anterior Cerebral artery OcclusioN) is a retrospective cohort study of the 2016 to 2020 U.S. National Inpatient Sample to investigate the outcomes of EVT versus best medical management (BMM) for ACA strokes in routine clinical practice. Adult patients with acute ischemic stroke due to isolated ACA occlusion and NIH stroke scale (NIHSS) of 6 or greater were included. The primary endpoint was rate of excellent outcome (routine hospital discharge without inpatient rehabilitation needs). Secondary endpoints include in-hospital mortality, intracranial hemorrhage (ICH), intraparenchymal hemorrhage (IPH), and subarachnoid hemorrhage (SAH). Multivariable logistic regression analyses were used to adjust for confounders, and mediation analyses were used to identify possible causal relationships.
Results 6,685 patients were included; 335 (5.0%) received EVT. Compared to BMM, EVT patients were younger (mean 67.2 versus 72.2 years, respectively; p=0.014) and had higher NIHSS (mean 16.0 versus 12.5, respectively; p<0.001). EVT was numerically but not statistically significantly associated with different rates of excellent outcomes compared to BMM in both unadjusted (13.4% vs. 7.5%, respectively; p=0.063) and multivariable analyses (aOR 2.26 [95%CI 0.99–5.17], p=0.053). Subgroup analyses revealed that EVT was significantly associated with higher odds of excellent outcomes among patients with NIHSS 10 or greater (aOR 3.35 [95%CI 1.06–10.58], p=0.039), those who did not receive prior thrombolysis (aOR 3.96 [95%CI 1.53–10.23], p=0.005), and those with embolic stroke etiology (aOR 4.03 [95%CI 1.21–13.47], p=0.024). EVT was not significantly associated with higher odds of in-hospital mortality in multivariable analysis (aOR 1.93 [95%CI 0.80–4.63], p=0.14); however, it was significantly associated with higher rates of ICH (22.4% vs. 8.5%, p<0.001), IPH (16.4% vs. 6.7%, p=0.003) and SAH (7.5% vs. 1.3%, p<0.001). A lack of net benefit with EVT was observed among thrombolysis-treated patients and those with non-embolic stroke etiology, which may be partially explained the high rates of IPH (10.4% suppression of treatment effect, p=0.066) and SAH (9.1% suppression, p=0.050) associated with EVT, respectively.
Conclusions EVT is seldomly performed for ACA occlusion strokes. The clinical benefit of EVT is uncertain, highly sensitive to patient and stroke characteristics, and likely suppressed by high rates of hemorrhagic complications. Formalizing patient selection criteria based on stroke severity, prior thrombolysis treatment, and stroke etiology may help optimize risk-benefit tradeoffs for ACA thrombectomy.
Disclosures H. Chen: None. M. Khunte: None. A. Malhotra: None. D. Gandhi: None. M. Colasurdo: None.