Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

Rohini Bhole, Nitin Goyal, Katherine Nearing, Andrey Belayev, Vinodh T. Doss, Lucas Elijovich, Daniel A. Hoit, Georgios Tsivgoulis, Andrei Alexandrov, Adam Arthur, Anne Alexandrov

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18 Citations (Scopus)

Abstract

Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria. Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (MRS) score≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month MRS score 0-2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (? ?8.2; 95% CI ?24.6 to ?8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable MRS (OR=0.97; 95% CI 0.28 to 3.35). Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

Original languageEnglish (US)
Pages (from-to)225-228
Number of pages4
JournalJournal of NeuroInterventional Surgery
Volume9
Issue number3
DOIs
StatePublished - Mar 1 2017

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Thrombectomy
Stroke
Cerebral Hemorrhage
National Institutes of Health (U.S.)
Mortality
Guideline Adherence
Stents
Observational Studies
Hospitalization
Catheters
Retrospective Studies
Guidelines
Hemorrhage
Therapeutics

All Science Journal Classification (ASJC) codes

  • Surgery
  • Clinical Neurology

Cite this

@article{eea68fc87003408e869fd7c607cff04f,
title = "Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria",
abstract = "Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria. Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49{\%}) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10{\%}), Alberta Stroke Program Early CT score <6 (6.5{\%}), premorbid modified Rankin Scale (MRS) score≥2 (27{\%}), M2 occlusion (10{\%}), posterior circulation (32{\%}), symptom to groin puncture >360 min (58{\%}). 26 (42{\%}) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45{\%} in those lacking top tier evidence compared with 26{\%} (p=0.044), and 3 month MRS score 0-2 was 33{\%} versus 46{\%}, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (? ?8.2; 95{\%} CI ?24.6 to ?8.2; p=0.321), 3 month mortality (OR=0.38; 95{\%} CI 0.08 to 1.41), or 3 month favorable MRS (OR=0.97; 95{\%} CI 0.28 to 3.35). Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.",
author = "Rohini Bhole and Nitin Goyal and Katherine Nearing and Andrey Belayev and Doss, {Vinodh T.} and Lucas Elijovich and Hoit, {Daniel A.} and Georgios Tsivgoulis and Andrei Alexandrov and Adam Arthur and Anne Alexandrov",
year = "2017",
month = "3",
day = "1",
doi = "10.1136/neurintsurg-2015-012206",
language = "English (US)",
volume = "9",
pages = "225--228",
journal = "Journal of NeuroInterventional Surgery",
issn = "1759-8478",
publisher = "BMJ Publishing Group",
number = "3",

}

TY - JOUR

T1 - Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

AU - Bhole, Rohini

AU - Goyal, Nitin

AU - Nearing, Katherine

AU - Belayev, Andrey

AU - Doss, Vinodh T.

AU - Elijovich, Lucas

AU - Hoit, Daniel A.

AU - Tsivgoulis, Georgios

AU - Alexandrov, Andrei

AU - Arthur, Adam

AU - Alexandrov, Anne

PY - 2017/3/1

Y1 - 2017/3/1

N2 - Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria. Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (MRS) score≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month MRS score 0-2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (? ?8.2; 95% CI ?24.6 to ?8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable MRS (OR=0.97; 95% CI 0.28 to 3.35). Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

AB - Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria. Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (MRS) score≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month MRS score 0-2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (? ?8.2; 95% CI ?24.6 to ?8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable MRS (OR=0.97; 95% CI 0.28 to 3.35). Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

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U2 - 10.1136/neurintsurg-2015-012206

DO - 10.1136/neurintsurg-2015-012206

M3 - Article

VL - 9

SP - 225

EP - 228

JO - Journal of NeuroInterventional Surgery

JF - Journal of NeuroInterventional Surgery

SN - 1759-8478

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