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Stroke. 2018 Oct;49(10):2398-2405. doi: 10.1161/STROKEAHA.118.022114.

Endovascular Thrombectomy for Mild Strokes: How Low Should We Go?

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From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston.
Department of Interventional Neurology, University of Texas-Rio Grande Valley, Harlingen (A.H.).
Department of Internal Medicine (C.C.), University of Texas Health Science Center at Houston.
Department of Diagnostic and Interventional Imaging (C.W.S.), University of Texas Health Science Center at Houston.
Department of Neurology and Neurosurgery (L.E., N.G.), University of Tennessee Health Sciences Center, Memphis.
Department of Neurology (R.K.), University of Tennessee Health Sciences Center, Memphis.
Department of Neurology, Kaiser Permanente Los Angeles, CA (N.S., A.W.).
Department of Neurology, Rush University Medical Center, Chicago, IL (M.C., R.C., R.M.).
Department of Neurology, Baylor University Medical Center, Texas A&M University, Dallas (O.M., R.H., D.G.).
Department of Neuroscience, Baylor University Medical Center, Dallas, TX (L.M.S.).
Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena).
Department of Neurology and Radiology, Kansas University Hospital, MO (M.A.).


Background and Purpose- Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) ≥6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS, <6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods- A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS <6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results- Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance ( P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions- Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS, <6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS ≥6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.


Spain; brain ischemia; humans; odds ratio; thrombectomy; thrombosis

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