If you want to be treated properly it would be best for you to have a large enough stroke to meet guidelines and obvious enough to not be mistaken for a mimic. Think you can do that? You will have to since our doctors don't have protocols for every type of stroke and have NOTHING in rehab that will get you 100% recovered.
Mild-Deficit Strokes: Endovascular vs Medical Tx Debate Rages On
Retrospective study suggests safety disadvantage for thrombectomy
Comparing mechanical thrombectomy and medical management for emergency large vessel occlusion (LVO) strokes where the patient had only mild neurological deficits, researchers found only one significant difference: in asymptomatic intracranial hemorrhages (ICH).A retrospective analysis of 251 consecutive stroke patients -- all presenting with NIH Stroke Scale (NIHSS) score under 6, reflecting mild impairment, and within 24 hours of symptom onset -- showed largely similar efficacy and safety outcomes at 3 months with mechanical thrombectomy versus medical therapy.
Specific results, after imputation for missing values and further adjustment, included:
- Favorable functional outcome (modified Rankin Scale [mRS] score 0-1): 63.1% vs 70.4% (adjusted OR 0.72, 95% CI 0.31-1.72)
- Functional independence (mRS score 0-2): 76.7% vs 85.2% (adjusted OR 0.47, 95% CI 0.14-1.64)
- Mortality: 9.7% vs 5.7% (adjusted OR 1.73, 95% CI 0.21-13.87)
- Symptomatic ICH: 4.4% vs 0.9% (adjusted OR 2.09, 95% CI 0.16-27.85)
This analysis was then included in a four-study meta-analysis, from which the researchers found that thrombectomy was associated with higher odds of symptomatic ICH in unadjusted analyses (OR 5.52, 95% CI 1.91-15.49) before losing significance upon adjustment (OR 2.06, 95% CI 0.49-8.63).
"Moreover, our meta-analysis failed to detect an independent association between treatment modality and asymptomatic ICH," Goyal's group noted.
"Our multicenter study coupled with the meta-analysis suggests similar outcomes of mechanical thrombectomy and best medical management in patients with stroke with mild-deficits emergency LVO, but no conclusions about treatment effect can be made," the researchers concluded.
Future randomized trials are needed to tell how endovascular therapy fares against medical therapy alone in these patients, they said.
"This area remains one of the highly debated topics of mechanical thrombectomy and stroke care. We know from milestone trials that thrombectomy is one of the most successful treatments in the history of medicine, but very few of the large trials actually enrolled patients with NIHSS less than 6. That is why guidelines do not include these patients, and they recommend thrombectomy for patients with NIHSS >6," commented Gabor Toth, MD, of the Cleveland Clinic, who was not involved with the study.
"However, in our clinical practice, this dilemma comes up fairly often, even though the overall number of these patents is probably low: what should we do with a patient with mild symptoms who is found to have an M1 occlusion? Is the risk of the procedure worth taking? Should we leave them alone or offer off-label therapy? Is the natural history of the disease benign enough to justify conservative management?"
Some retrospective studies on this population have shown benefit of thrombectomy over medical management, while others have not. "So this study is an excellent addition to our current understanding of this challenging patient population, but the jury is still out, and standardized randomized controlled trials are definitely needed to prove if mechanical thrombectomy is efficacious in these patients," Toth told MedPage Today.
The 251 stroke patients in the present study had presented to 16 centers in North America, Europe, and Asia. They were split between those treated with mechanical thrombectomy (n=138) or medical therapy (n=113). Average age was 65 years, and about 46% were women.
Baseline differences between groups include the mechanical thrombectomy arm group having fewer smokers, getting borderline more IV tPA, and presenting with greater NIHSS scores and more proximal occlusions.
"Theoretically, proximal anterior circulation occlusions might predispose patients to a higher risk of worsening. This might lead clinicians to offer mechanical thrombectomy to these patients with emergency LVO despite low NIHSS scores at hospital admission," Goyal and colleagues surmised.
"The lack of improved clinical outcomes in the mechanical thrombectomy group is consequently counterintuitive and may be attributed to intrinsic ischemic preconditioning in patients with mild-deficits emergency LVO owing to good collateral status," they continued, noting that good collaterals were observed in 81% of their cohort.
It's also possible that the ischemic territory at risk in these patients may be restricted to a small cerebral area, negating the potential beneficial effect of endovascular reperfusion, the authors added. "Thus, the optimal selection of patients with mild-deficits emergency LVO for mechanical thrombectomy may require advanced neuroimaging to determine whether certain perfusion or collateral thresholds predict neurologic deterioration."
Chief among study's limitations cited by Goyal's group were its retrospective, non-randomized nature and relatively small sample size, which may have left the study underpowered to detect real differences.
Toth cited other caveats, including that treatments were not necessarily the same in different institutions and that the paper didn't report the breakdown of mild deficits.
He also observed that a randomized trial will have its challenges in this population.
"Overall, it is a small population, recruitment will likely be slower than larger trials, and since the conservative patient arm likely will have relatively higher proportion of good outcomes, mechanical thrombectomy has to be done efficiently and safely to show a benefit over conservative medical management," Toth said.
His own group recently published a prospective study showing the safety and feasibility of thrombectomy in NIHSS below 6.
"Although we also saw great clinical outcomes, our study was not randomized, and therefore not powered to show efficacy," he cautioned. "However, the idea was that this needed to gather this safety data first before proceeding with a subsequent randomized trial."
Goyal had no conflicts listed.
Study co-authors reported multiple ties to industry.
Toth is a consultant for DynaMed and Medtronic.
Study co-authors reported multiple ties to industry.
Toth is a consultant for DynaMed and Medtronic.
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