Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment

Amrou Sarraj, Navdeep Sangha, Muhammad Shazam Hussain, Dolora Wisco, Nirav Vora, Lucas Elijovich, Nitin Goyal, Michael Abraham, Manoj Mittal, Lei Feng, Abel Wu, Vallabh Janardhan, Suman Nalluri, Albert J. Yoo, Megan George, Randall Edgell, Rutvij J. Shah, Clark Sitton, Emilio Supsupin, Suhas Bajgur & 6 others M. Carter Denny, Peng R. Chen, Mark Dannenbaum, Sheryl Martin-Schild, Sean I. Savitz, Rishi Gupta

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Abstract

IMPORTANCE Randomized clinical trials have shown the superiority of endovascular therapy (EVT) compared with best medical management for acute ischemic strokes with large vessel occlusion (LVO) in the anterior circulation. However, of 1287 patients enrolled in 5 trials, 94 with isolated second (M2) segment occlusions were randomized and 51 of these received EVT, thereby limiting evidence for treating isolated M2 segment occlusions as reflected in American Heart Association guidelines. OBJECTIVE To evaluate EVT safety and effectiveness in M2 occlusions in a cohort of patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study pooled patients with acute ischemic strokes and LVO isolated to M2 segments from 10 US centers. Patients with acute ischemic strokes and LVO inM2 segments presenting within 8 hours from their last known normal clinical status (LKN) from January 1, 2012, to April 30, 2015, were divided based on their treatment into EVT and medical management groups. Logistic regression was used to compare the 2 groups. Univariate and multivariate analyses evaluated associations with good outcome in the EVT group. MAIN OUTCOMES AND MEASURES The primary outcomewas the 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome); the secondary outcome was symptomatic intracerebral hemorrhage. RESULTS A total of 522 patients (256 men [49%]; 266 women [51%]; mean [SD] age, 68 [14.3] years) were identified, of whom 288 received EVT and 234 received best medical management. Patients in the medical management group were older (median [interquartile range] age, 73 [60-81] vs 68 [56-78] years) and had higher rates of intravenous tissue plasminogen activator treatment (174 [74.4%] vs 172 [59.7%]); otherwise the 2 groups were balanced. The rate of good outcomes was higher for EVT (181 [62.8%]) than for medical management (83 [35.4%]). The EVT group had 3 times the odds of a good outcome as the medical management group (odds ratio [OR], 3.1; 95%CI, 2.1-4.4; P < .001) even after adjustment for age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomographic Score (ASPECTS), intravenous tissue plasminogen activator treatment, and time from LKN to arrival in the emergency department (OR, 3.2; 95%CI, 2-5.2; P < .001). No statistical difference in symptomatic intracerebral hemorrhage was found (5.6%vs 2.1%for the EVT group vs the medical management group; P = .10). The treatment effect did not change after adjusting for center (OR, 3.3; 95%CI, 1.9-5.8; P < .001). Age, NIHSS score, ASPECTS, time from LKN to reperfusion, and successful reperfusion score of at least 2b (range, 0 [no perfusion] to 3 [full perfusion with filling of all distal branches]) were independently associated with good outcome of EVT. A linear association was found between good outcome and time from LKN to reperfusion. CONCLUSIONS AND RELEVANCE Although a randomized clinical trial is needed to confirm these findings, available data suggest that EVT is reasonable, safe, and effective for LVO of the M2 segment relative to best medical management.

Original languageEnglish (US)
Pages (from-to)1291-1296
Number of pages6
JournalJAMA Neurology
Volume73
Issue number11
DOIs
StatePublished - Nov 1 2016

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Middle Cerebral Artery Infarction
Stroke
Therapeutics
Group Psychotherapy
Reperfusion
Alberta
Odds Ratio
Cerebral Hemorrhage
National Institutes of Health (U.S.)
Tissue Plasminogen Activator
Randomized Controlled Trials
Perfusion
Hospital Emergency Service
Cohort Studies
Multivariate Analysis
Retrospective Studies
Logistic Models
Guidelines

All Science Journal Classification (ASJC) codes

  • Clinical Neurology

Cite this

Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment. / Sarraj, Amrou; Sangha, Navdeep; Hussain, Muhammad Shazam; Wisco, Dolora; Vora, Nirav; Elijovich, Lucas; Goyal, Nitin; Abraham, Michael; Mittal, Manoj; Feng, Lei; Wu, Abel; Janardhan, Vallabh; Nalluri, Suman; Yoo, Albert J.; George, Megan; Edgell, Randall; Shah, Rutvij J.; Sitton, Clark; Supsupin, Emilio; Bajgur, Suhas; Denny, M. Carter; Chen, Peng R.; Dannenbaum, Mark; Martin-Schild, Sheryl; Savitz, Sean I.; Gupta, Rishi.

In: JAMA Neurology, Vol. 73, No. 11, 01.11.2016, p. 1291-1296.

Research output: Contribution to journalArticle

Sarraj, A, Sangha, N, Hussain, MS, Wisco, D, Vora, N, Elijovich, L, Goyal, N, Abraham, M, Mittal, M, Feng, L, Wu, A, Janardhan, V, Nalluri, S, Yoo, AJ, George, M, Edgell, R, Shah, RJ, Sitton, C, Supsupin, E, Bajgur, S, Denny, MC, Chen, PR, Dannenbaum, M, Martin-Schild, S, Savitz, SI & Gupta, R 2016, 'Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment', JAMA Neurology, vol. 73, no. 11, pp. 1291-1296. https://doi.org/10.1001/jamaneurol.2016.2773
Sarraj, Amrou ; Sangha, Navdeep ; Hussain, Muhammad Shazam ; Wisco, Dolora ; Vora, Nirav ; Elijovich, Lucas ; Goyal, Nitin ; Abraham, Michael ; Mittal, Manoj ; Feng, Lei ; Wu, Abel ; Janardhan, Vallabh ; Nalluri, Suman ; Yoo, Albert J. ; George, Megan ; Edgell, Randall ; Shah, Rutvij J. ; Sitton, Clark ; Supsupin, Emilio ; Bajgur, Suhas ; Denny, M. Carter ; Chen, Peng R. ; Dannenbaum, Mark ; Martin-Schild, Sheryl ; Savitz, Sean I. ; Gupta, Rishi. / Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment. In: JAMA Neurology. 2016 ; Vol. 73, No. 11. pp. 1291-1296.
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abstract = "IMPORTANCE Randomized clinical trials have shown the superiority of endovascular therapy (EVT) compared with best medical management for acute ischemic strokes with large vessel occlusion (LVO) in the anterior circulation. However, of 1287 patients enrolled in 5 trials, 94 with isolated second (M2) segment occlusions were randomized and 51 of these received EVT, thereby limiting evidence for treating isolated M2 segment occlusions as reflected in American Heart Association guidelines. OBJECTIVE To evaluate EVT safety and effectiveness in M2 occlusions in a cohort of patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study pooled patients with acute ischemic strokes and LVO isolated to M2 segments from 10 US centers. Patients with acute ischemic strokes and LVO inM2 segments presenting within 8 hours from their last known normal clinical status (LKN) from January 1, 2012, to April 30, 2015, were divided based on their treatment into EVT and medical management groups. Logistic regression was used to compare the 2 groups. Univariate and multivariate analyses evaluated associations with good outcome in the EVT group. MAIN OUTCOMES AND MEASURES The primary outcomewas the 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome); the secondary outcome was symptomatic intracerebral hemorrhage. RESULTS A total of 522 patients (256 men [49{\%}]; 266 women [51{\%}]; mean [SD] age, 68 [14.3] years) were identified, of whom 288 received EVT and 234 received best medical management. Patients in the medical management group were older (median [interquartile range] age, 73 [60-81] vs 68 [56-78] years) and had higher rates of intravenous tissue plasminogen activator treatment (174 [74.4{\%}] vs 172 [59.7{\%}]); otherwise the 2 groups were balanced. The rate of good outcomes was higher for EVT (181 [62.8{\%}]) than for medical management (83 [35.4{\%}]). The EVT group had 3 times the odds of a good outcome as the medical management group (odds ratio [OR], 3.1; 95{\%}CI, 2.1-4.4; P < .001) even after adjustment for age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomographic Score (ASPECTS), intravenous tissue plasminogen activator treatment, and time from LKN to arrival in the emergency department (OR, 3.2; 95{\%}CI, 2-5.2; P < .001). No statistical difference in symptomatic intracerebral hemorrhage was found (5.6{\%}vs 2.1{\%}for the EVT group vs the medical management group; P = .10). The treatment effect did not change after adjusting for center (OR, 3.3; 95{\%}CI, 1.9-5.8; P < .001). Age, NIHSS score, ASPECTS, time from LKN to reperfusion, and successful reperfusion score of at least 2b (range, 0 [no perfusion] to 3 [full perfusion with filling of all distal branches]) were independently associated with good outcome of EVT. A linear association was found between good outcome and time from LKN to reperfusion. CONCLUSIONS AND RELEVANCE Although a randomized clinical trial is needed to confirm these findings, available data suggest that EVT is reasonable, safe, and effective for LVO of the M2 segment relative to best medical management.",
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T1 - Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment

AU - Sarraj, Amrou

AU - Sangha, Navdeep

AU - Hussain, Muhammad Shazam

AU - Wisco, Dolora

AU - Vora, Nirav

AU - Elijovich, Lucas

AU - Goyal, Nitin

AU - Abraham, Michael

AU - Mittal, Manoj

AU - Feng, Lei

AU - Wu, Abel

AU - Janardhan, Vallabh

AU - Nalluri, Suman

AU - Yoo, Albert J.

AU - George, Megan

AU - Edgell, Randall

AU - Shah, Rutvij J.

AU - Sitton, Clark

AU - Supsupin, Emilio

AU - Bajgur, Suhas

AU - Denny, M. Carter

AU - Chen, Peng R.

AU - Dannenbaum, Mark

AU - Martin-Schild, Sheryl

AU - Savitz, Sean I.

AU - Gupta, Rishi

PY - 2016/11/1

Y1 - 2016/11/1

N2 - IMPORTANCE Randomized clinical trials have shown the superiority of endovascular therapy (EVT) compared with best medical management for acute ischemic strokes with large vessel occlusion (LVO) in the anterior circulation. However, of 1287 patients enrolled in 5 trials, 94 with isolated second (M2) segment occlusions were randomized and 51 of these received EVT, thereby limiting evidence for treating isolated M2 segment occlusions as reflected in American Heart Association guidelines. OBJECTIVE To evaluate EVT safety and effectiveness in M2 occlusions in a cohort of patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study pooled patients with acute ischemic strokes and LVO isolated to M2 segments from 10 US centers. Patients with acute ischemic strokes and LVO inM2 segments presenting within 8 hours from their last known normal clinical status (LKN) from January 1, 2012, to April 30, 2015, were divided based on their treatment into EVT and medical management groups. Logistic regression was used to compare the 2 groups. Univariate and multivariate analyses evaluated associations with good outcome in the EVT group. MAIN OUTCOMES AND MEASURES The primary outcomewas the 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome); the secondary outcome was symptomatic intracerebral hemorrhage. RESULTS A total of 522 patients (256 men [49%]; 266 women [51%]; mean [SD] age, 68 [14.3] years) were identified, of whom 288 received EVT and 234 received best medical management. Patients in the medical management group were older (median [interquartile range] age, 73 [60-81] vs 68 [56-78] years) and had higher rates of intravenous tissue plasminogen activator treatment (174 [74.4%] vs 172 [59.7%]); otherwise the 2 groups were balanced. The rate of good outcomes was higher for EVT (181 [62.8%]) than for medical management (83 [35.4%]). The EVT group had 3 times the odds of a good outcome as the medical management group (odds ratio [OR], 3.1; 95%CI, 2.1-4.4; P < .001) even after adjustment for age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomographic Score (ASPECTS), intravenous tissue plasminogen activator treatment, and time from LKN to arrival in the emergency department (OR, 3.2; 95%CI, 2-5.2; P < .001). No statistical difference in symptomatic intracerebral hemorrhage was found (5.6%vs 2.1%for the EVT group vs the medical management group; P = .10). The treatment effect did not change after adjusting for center (OR, 3.3; 95%CI, 1.9-5.8; P < .001). Age, NIHSS score, ASPECTS, time from LKN to reperfusion, and successful reperfusion score of at least 2b (range, 0 [no perfusion] to 3 [full perfusion with filling of all distal branches]) were independently associated with good outcome of EVT. A linear association was found between good outcome and time from LKN to reperfusion. CONCLUSIONS AND RELEVANCE Although a randomized clinical trial is needed to confirm these findings, available data suggest that EVT is reasonable, safe, and effective for LVO of the M2 segment relative to best medical management.

AB - IMPORTANCE Randomized clinical trials have shown the superiority of endovascular therapy (EVT) compared with best medical management for acute ischemic strokes with large vessel occlusion (LVO) in the anterior circulation. However, of 1287 patients enrolled in 5 trials, 94 with isolated second (M2) segment occlusions were randomized and 51 of these received EVT, thereby limiting evidence for treating isolated M2 segment occlusions as reflected in American Heart Association guidelines. OBJECTIVE To evaluate EVT safety and effectiveness in M2 occlusions in a cohort of patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study pooled patients with acute ischemic strokes and LVO isolated to M2 segments from 10 US centers. Patients with acute ischemic strokes and LVO inM2 segments presenting within 8 hours from their last known normal clinical status (LKN) from January 1, 2012, to April 30, 2015, were divided based on their treatment into EVT and medical management groups. Logistic regression was used to compare the 2 groups. Univariate and multivariate analyses evaluated associations with good outcome in the EVT group. MAIN OUTCOMES AND MEASURES The primary outcomewas the 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome); the secondary outcome was symptomatic intracerebral hemorrhage. RESULTS A total of 522 patients (256 men [49%]; 266 women [51%]; mean [SD] age, 68 [14.3] years) were identified, of whom 288 received EVT and 234 received best medical management. Patients in the medical management group were older (median [interquartile range] age, 73 [60-81] vs 68 [56-78] years) and had higher rates of intravenous tissue plasminogen activator treatment (174 [74.4%] vs 172 [59.7%]); otherwise the 2 groups were balanced. The rate of good outcomes was higher for EVT (181 [62.8%]) than for medical management (83 [35.4%]). The EVT group had 3 times the odds of a good outcome as the medical management group (odds ratio [OR], 3.1; 95%CI, 2.1-4.4; P < .001) even after adjustment for age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomographic Score (ASPECTS), intravenous tissue plasminogen activator treatment, and time from LKN to arrival in the emergency department (OR, 3.2; 95%CI, 2-5.2; P < .001). No statistical difference in symptomatic intracerebral hemorrhage was found (5.6%vs 2.1%for the EVT group vs the medical management group; P = .10). The treatment effect did not change after adjusting for center (OR, 3.3; 95%CI, 1.9-5.8; P < .001). Age, NIHSS score, ASPECTS, time from LKN to reperfusion, and successful reperfusion score of at least 2b (range, 0 [no perfusion] to 3 [full perfusion with filling of all distal branches]) were independently associated with good outcome of EVT. A linear association was found between good outcome and time from LKN to reperfusion. CONCLUSIONS AND RELEVANCE Although a randomized clinical trial is needed to confirm these findings, available data suggest that EVT is reasonable, safe, and effective for LVO of the M2 segment relative to best medical management.

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