Skip to main content

Advertisement

SpringerLink
Log in

Mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in the anterior circulation and low baseline National Institute of Health Stroke Scale score: a multicenter retrospective matched analysis

  • Original Article
  • Published:
Neurological Sciences Aims and scope Submit manuscript

Abstract

Background and Purpose

The benefit of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and baseline mild neurological symptoms remains unclear. The purpose of this study was to evaluate the effectiveness of MT in this subgroup of patients.

Methods

The databases of 9 high-volume Italian stroke centers were retrospectively screened for patients with LVO in the anterior circulation and a baseline National Institute of Health Stroke Scale (NIHSS) score ≤ 5 that received either immediate MT or best medical management (BMM) with the possibility of rescue MT upon neurological worsening. Primary outcome measure was a modified Rankin Scale score of 0–1 at 90 days. Propensity score matching (PSM) analysis was used to estimate the treatment effect of immediate MT compared to BMM/rescue MT.

Results

Two hundred and seventy-two patients received immediate MT (MT group). The BMM/rescue MT group included 41 patients. The primary outcome was achieved in 78.6% (n = 246) of overall patients, with a higher proportion in the MT group (80.5% vs. 65.9%, p = 0.03) in unadjusted analysis. After PSM, patients in the MT group had a 19.5% higher chance of excellent outcome at 90 days compared to the BMM/Rescue MT group with a similar risk of death from any cause.

Conclusions

Our experience is in favor of a potential benefit of MT also in patients with LVO and a NIHSS score ≤ 5 at the time of groin puncture. Nonetheless, this issue waits for a clear-cut recommendation in a dedicated clinical trial.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20. https://doi.org/10.1056/NEJMoa1411587

    Article  CAS  PubMed  Google Scholar 

  2. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372(11):1009–1018. https://doi.org/10.1056/NEJMoa1414792

    Article  CAS  PubMed  Google Scholar 

  3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030. https://doi.org/10.1056/NEJMoa1414905

    Article  CAS  PubMed  Google Scholar 

  4. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372(24):2296–2306. https://doi.org/10.1056/NEJMoa1503780

    Article  CAS  PubMed  Google Scholar 

  5. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372(24):2285–2295. https://doi.org/10.1056/NEJMoa1415061

    Article  CAS  PubMed  Google Scholar 

  6. Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T et al (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15(11):1138–1147. https://doi.org/10.1016/S1474-4422(16)30177-6

    Article  CAS  PubMed  Google Scholar 

  7. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K et al (2019) Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 50(12):e344–e418. https://doi.org/10.1161/STR.0000000000000211

    Article  PubMed  Google Scholar 

  8. Kim JT, Heo SH, Yoon W, Choi KH, Park MS, Saver JL et al (2016) Clinical outcomes of patients with acute minor stroke receiving rescue IA therapy following early neurological deterioration. J Neurointerv Surg 8(5):461–465. https://doi.org/10.1136/neurintsurg-2015-011690

    Article  PubMed  Google Scholar 

  9. Pfaff J, Herweh C, Pham M, Schonenberger S, Nagel S, Ringleb PA et al (2016) Mechanical thrombectomy in patients with acute ischemic stroke and lower NIHSS Scores: recanalization rates, periprocedural complications, and clinical outcome. Am J Neuroradiol 37(11):2066–2071. https://doi.org/10.3174/ajnr.A4862

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Goyal N, Tsivgoulis G, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT et al (2020) Medical management vs mechanical thrombectomy for mild strokes: an international multicenter study and systematic review and meta-analysis. JAMA Neurol 77(1):16–24. https://doi.org/10.1001/jamaneurol.2019.3112

    Article  PubMed  Google Scholar 

  11. Saleem Y, Nogueira RG, Rodrigues GM, Kim S, Sharashidze V, Frankel M et al (2020) Acute neurological deterioration in large vessel occlusions and mild symptoms managed medically. Stroke 51(5):1428–1434. https://doi.org/10.1161/STROKEAHA.119.027011

    Article  PubMed  Google Scholar 

  12. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387(10029):1723–1731. https://doi.org/10.1016/S0140-6736(16)00163-X

    Article  PubMed  Google Scholar 

  13. Heldner MR, Jung S, Zubler C, Mordasini P, Weck A, Mono ML et al (2015) Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients. J Neurol Neurosurg Psychiatry 86(7):755–760. https://doi.org/10.1136/jnnp-2014-308401

    Article  PubMed  Google Scholar 

  14. Mokin M, Masud MW, Dumont TM, Ahmad G, Kass-Hout T, Snyder KV et al (2014) Outcomes in patients with acute ischemic stroke from proximal intracranial vessel occlusion and NIHSS score below 8. J Neurointerv Surg 6(6):413–417. https://doi.org/10.1136/neurintsurg-2013-010720

    Article  PubMed  Google Scholar 

  15. Messer MP, Schonenberger S, Mohlenbruch MA, Pfaff J, Herweh C, Ringleb PA et al (2017) Minor stroke syndromes in large-vessel occlusions: mechanical thrombectomy or thrombolysis only? Am J Neuroradiol 38(6):1177–1179. https://doi.org/10.3174/ajnr.A5164

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Nagel S, Bouslama M, Krause LU, Kupper C, Messer M, Petersen M et al (2018) Mechanical thrombectomy in patients with milder strokes and large vessel occlusions. Stroke 49(10):2391–2397. https://doi.org/10.1161/STROKEAHA.118.021106

    Article  PubMed  Google Scholar 

  17. Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M et al (2019) European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic Stroke. Endorsed by Stroke Alliance for Europe (SAFE). Eur Stroke J 4(1):6–12. https://doi.org/10.1177/2396987319832140

    Article  PubMed  PubMed Central  Google Scholar 

  18. Italian Stroke Association - Stroke Prevention and Education Awareness (2020) Guidelines for Revascularization Therapies. Available from: https://www.iso-stroke.it/wp-content/uploads/2020/10/linee_guida_terapie_rivascolarizzazione.pdf. Accessed 5 Nov 2021

  19. Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 355(9216):1670–1674. https://doi.org/10.1016/s0140-6736(00)02237-6

    Article  CAS  PubMed  Google Scholar 

  20. Menon BK, d’Esterre CD, Qazi EM, Almekhlafi M, Hahn L, Demchuk AM et al (2015) Multiphase CT angiography: a new tool for the imaging triage of patients with acute ischemic stroke. Radiology 275(2):510–520. https://doi.org/10.1148/radiol.15142256

    Article  PubMed  Google Scholar 

  21. Ilyas A, Chen CJ, Ding D, Foreman PM, Buell TJ, Ironside N et al (2018) Endovascular mechanical thrombectomy for acute ischemic stroke under general anesthesia versus conscious sedation: a systematic review and meta-analysis. World Neurosurg 112:e355–e367. https://doi.org/10.1016/j.wneu.2018.01.049

    Article  PubMed  Google Scholar 

  22. Zhang Y, Jia L, Fang F, Ma L, Cai B, Faramand A (2019) General anesthesia versus conscious sedation for intracranial mechanical thrombectomy: a systematic review and meta-analysis of randomized clinical trials. J Am Heart Assoc 8(12):e011754. https://doi.org/10.1161/JAHA.118.011754

    Article  PubMed  PubMed Central  Google Scholar 

  23. Gerber JC, Miaux YJ, von Kummer R (2015) Scoring flow restoration in cerebral angiograms after endovascular revascularization in acute ischemic stroke patients. Neuroradiology 57(3):227–240. https://doi.org/10.1007/s00234-014-1460-x

    Article  PubMed  Google Scholar 

  24. von Kummer R, Broderick JP, Campbell BC, Demchuk A, Goyal M, Hill MD et al (2015) The Heidelberg Bleeding Classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke 46(10):2981–2986. https://doi.org/10.1161/STROKEAHA.115.010049

    Article  Google Scholar 

  25. Gomila R (2021) Logistic or linear? Estimating causal effects of experimental treatments on binary outcomes using regression analysis. J Exp Psychol Gen 150(4):700–709. https://doi.org/10.1037/xge0000920

    Article  PubMed  Google Scholar 

  26. Fischer U, Baumgartner A, Arnold M, Nedeltchev K, Gralla J, De Marchis GM et al (2010) What is a minor stroke? Stroke 41(4):661–666. https://doi.org/10.1161/STROKEAHA.109.572883

    Article  PubMed  Google Scholar 

  27. Salsano G, Pracucci G, Mavilio N, Saia V, BdP M, Malfatto L et al (2021) Complications of mechanical thrombectomy for acute ischemic stroke: incidence, risk factors, and clinical relevance in the Italian Registry of Endovascular Treatment in acute stroke. Int J Stroke 16(7):818–827. https://doi.org/10.1177/1747493020976681

    Article  PubMed  Google Scholar 

  28. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W et al (2020) Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med 382(21):1981–1993. https://doi.org/10.1056/NEJMoa2001123

    Article  CAS  PubMed  Google Scholar 

  29. Kandregula S, Savardekar AR, Sharma P, McLarty J, Kosty J, Trosclair K et al (2021) Direct thrombectomy versus bridging thrombolysis with mechanical thrombectomy in middle cerebral artery stroke: a real-world analysis through National Inpatient Sample data. Neurosurg Focus 51(1):E4. https://doi.org/10.3171/2021.4.FOCUS21132

    Article  PubMed  Google Scholar 

  30. Haussen DC, Bouslama M, Grossberg JA, Anderson A, Belagage S, Frankel M et al (2017) Too good to intervene? Thrombectomy for large vessel occlusion strokes with minimal symptoms: an intention-to-treat analysis. J Neurointerv Surg 9(10):917–921. https://doi.org/10.1136/neurintsurg-2016-012633

    Article  PubMed  Google Scholar 

  31. Seners P, Perrin C, Lapergue B, Henon H, Debiais S, Sablot D et al (2020) Bridging therapy or IV thrombolysis in minor stroke with large vessel occlusion. Ann Neurol 88(1):160–169. https://doi.org/10.1002/ana.25756

    Article  CAS  PubMed  Google Scholar 

  32. Dargazanli C, Arquizan C, Gory B, Consoli A, Labreuche J, Redjem H et al (2017) Mechanical thrombectomy for minor and mild stroke patients harboring large vessel occlusion in the anterior circulation: a multicenter cohort study. Stroke 48(12):3274–3281. https://doi.org/10.1161/STROKEAHA.117.018113

    Article  PubMed  Google Scholar 

  33. Volny O, Zerna C, Tomek A, Bar M, Rocek M, Padr R et al (2020) Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke. Neurology 95(24):e3364–e3372. https://doi.org/10.1212/WNL.0000000000010955

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Mokin M, Ansari SA, McTaggart RA, Bulsara KR, Goyal M, Chen M et al (2019) Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 11(3):215–220. https://doi.org/10.1136/neurintsurg-2018-014640

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Andrea Maria Alexandre and Iacopo Valente contributed equally to this work.

Authors and Affiliations

  1. Area Diagnostica Per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Andrea Maria Alexandre, Iacopo Valente & Alessandro Pedicelli

  2. Dipartimento di Scienze della Vita e di Sanità Pubblica, Università Cattolica del S. Cuore, Rome, Italy

    Angelo Maria Pezzullo

  3. Università Cattolica del S. Cuore, Rome, Italy

    Francesca Colò, Luca Scarcia, Andrea Romi, Paolo Calabresi, Giacomo Della Marca & Aldobrando Broccolini

  4. Neuroradiologia, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Mariangela Piano & Antonio Macera

  5. UOC Neuroradiologia, Azienda Ospedaliera Universitaria di Padova, Padua, Italy

    Joseph Domenico Gabrieli & Giacomo Cester

  6. UO Neuroradiologia, AOU Policlinico G. Martino, Messina, Italy

    Antonio Armando Caragliano & Sergio Lucio Vinci

  7. UO Neuroradiologia, AUSL Romagna, Cesena-Rimini, Italy

    Maria Ruggiero & Christian Commodaro

  8. Neuroradiologia Interventistica, Azienda Ospedaliero-Universitaria Sant’Anna, Ferrara, Italy

    Andrea Saletti

  9. UO Neuroradiologia, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy

    Guido Andrea Lazzarotti & Mirco Cosottini

  10. Dipartimento di Biomedicina e Prevenzione, Policlinico Universitario di Roma “Tor Vergata”, Rome, Italy

    Valerio Da Ros & Luigi Bellini

  11. UOC Neuroradiologia, Ospedale V. Fazzi, Lecce, Italy

    Emilio Lozupone & Adriana Paladini

  12. UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Valerio Brunetti, Roberta Morosetti, Giovanni Frisullo, Paolo Calabresi, Giacomo Della Marca & Aldobrando Broccolini

Authors
  1. Andrea Maria Alexandre
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Iacopo Valente
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alessandro Pedicelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Angelo Maria Pezzullo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Francesca Colò
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Luca Scarcia
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Andrea Romi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mariangela Piano
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Antonio Macera
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Joseph Domenico Gabrieli
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Giacomo Cester
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Antonio Armando Caragliano
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Sergio Lucio Vinci
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Maria Ruggiero
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Christian Commodaro
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Andrea Saletti
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Guido Andrea Lazzarotti
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Mirco Cosottini
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Valerio Da Ros
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Luigi Bellini
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. Emilio Lozupone
    View author publications

    You can also search for this author in PubMed Google Scholar

  22. Adriana Paladini
    View author publications

    You can also search for this author in PubMed Google Scholar

  23. Valerio Brunetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  24. Roberta Morosetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  25. Giovanni Frisullo
    View author publications

    You can also search for this author in PubMed Google Scholar

  26. Paolo Calabresi
    View author publications

    You can also search for this author in PubMed Google Scholar

  27. Giacomo Della Marca
    View author publications

    You can also search for this author in PubMed Google Scholar

  28. Aldobrando Broccolini
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: Andrea Alexandre, Iacopo Valente, Giacomo Della Marca, and Aldobrando Broccolini; Methodology: Andrea Alexandre, Iacopo Valente, and Aldobrando Broccolini; Formal analysis and investigation: Andrea Alexandre, Iacopo Valente, Alessandro Pedicelli, Angelo Maria Pezzullo, Francesca Colò, Luca Scarcia, Andrea Romi, Mariangela Piano, Antonio Macera, Joseph Domenico Gabrieli, Giacomo Cester, Antonio Armando Caragliano, Sergio Lucio Vinci, Maria Ruggiero, Christian Commodaro, Andrea Saletti, Guido Andrea Lazzarotti, Mirco Cosottini, Valerio Da Ros, Luigi Bellini, Emilio Lozupone, Adriana Paladini, Valerio Brunetti, Roberta Morosetti, Giovanni Frisullo, Giacomo Della Marca, and Aldobrando Broccolini; Writing—original draft preparation: Andrea Alexandre, Iacopo Valente, Paolo Calabresi, Giacomo Della Marca, and Aldobrando Broccolini; Writing—review and editing: Andrea Alexandre, Iacopo Valente, and Aldobrando Broccolini.

Corresponding author

Correspondence to Aldobrando Broccolini.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Ethical approval

The study fully adheres to the ethical principles of the Declaration of Helsinki as well as GCP guidelines. Approval was granted by the Ethics Committee of the Fondazione Policlinico Universitario A. Gemelli IRCCS (protocol number 6410/20, ID 3004).

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 116 KB)

Supplementary file2 (JPG 663 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alexandre, A.M., Valente, I., Pedicelli, A. et al. Mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in the anterior circulation and low baseline National Institute of Health Stroke Scale score: a multicenter retrospective matched analysis. Neurol Sci 43, 3105–3112 (2022). https://doi.org/10.1007/s10072-021-05771-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10072-021-05771-5

Keywords

Search

Navigation