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Medical Therapy Vs Endovascular Therapy: Similar Outcomes for Mild Strokes

Mechanical thrombectomy had similar safety and efficacy outcomes as best medical management at three months in patients with mild-deficits emergency large-vessel occlusion (mELVO) strokes. However, beyond the risks for intracerebral hemorrhage, the analysis could not document any other independent associations between treatment groups and safety or efficacy outcomes, according to a study published on September 23 in the online issue of JAMA Neurology.

The researchers, led by Nitin Goyal, MD, of the University of Tennessee Health Science Center in Memphis, reported a higher odds of asymptomatic intracerebral hemorrhage (ICH) after mechanical thrombectomy (22.3 percent vs. 3.2 percent). After adjustment for confounding factors, however, the association was not statistically significant.

"[O]ur multicenter study coupled with a comprehensive meta-analysis documented similar outcomes between MT [mechanical thrombectomy] and bMM [best medical management] in patients with AIS [acute ischemic stroke] with mELVO, but no conclusions about treatment effect can be made," Dr. Goyal and his colleagues, wrote.

Mechanical thrombectomy has proven to be a life-saving endovascular treatment for patients with devastating strokes caused by ELVO when administered up to 24 hours of symptom onset, the study authors noted. Its safety and efficacy have been established for treating moderate-to-severe ELVO strokes, but its benefit for patients with mild stroke symptoms compared with best medical management in the emergency department remains unclear.

Previous multicenter studies suggested a potential benefit with mechanical thrombectomy in patients with ELVO and low National Institutes of Health Stroke Scale scores (NIHSS)—widely used to neurological symptoms, such as impaired movement, and determine treatment—while other studies reported similar safety and efficacy outcomes in mELVO.

To comparatively evaluate the safety and effectiveness of mechanical thrombectomy versus best medical management among patients with acute ischemic stroke with mELVO, the researchers conducted a retrospective analysis of 251 consecutive stroke patients who presented to 16 centers in North America, Europe, and Asia, during a five-year period. Researchers divided patients between those treated with mechanical thrombectomy (n=138) or medical therapy (n=113). The average age was 65 years; 46 percent were women.

Among baseline differences between the two treatment groups, the mechanical thrombectomy cohort had more proximal occlusions, intravenous thrombolysis, and higher NIHSS scores and included fewer smokers.

After further adjustment, however, the researchers found no differences in favorable functional outcomes in both groups at three months (63.1 percent vs 70.4 percent; p= .26); functional independence (76.7 percent vs 85.2 percent; p= .12); and mortality (9.7 percent vs 5.7 percent; p= .28).

Following their systematic review and meta-analysis, no conclusions about treatment effect could be made. Further research is warranted to determine how endovascular therapy fares against medical therapy in this subgroup of patients, the study authors concluded.

Study limitations included its retrospective, non-randomized nature and small sample size, which could have hindered the ability to detect real differences treatment modality and outcomes.

Dr. Goyal reported no conflicting interests. Multiple study authors reported multiple ties to the industry.

Link Up for More Information:

Goyal N, Tsivgoulis G, Malhotra K, et al. Medical management vs mechanical thrombectomy for mild strokes: An international multicenter study and systematic review and meta-analysis. JAMA Neurol 2019; Epub 23 Sep 2019.