Impact of the Thrombectomy Trials on the Management and Outcome of Large Vessel Stroke: Data From the Lyon Stroke Center

Lots of statistics to make sure laypersons can't use this and ask intelligent question of their doctors.  Again with the cherry picking of patients. NO stroke survivor should be left behind.

Impact of the Thrombectomy Trials on the Management and Outcome of Large Vessel Stroke: Data From the Lyon Stroke Center 

Louis Viannay¹, Julie Haesebaert², Fannie Florin³, Roberto Riva¹, Laura Mechtouff³, Benjamin Gory¹, Elodie Ong³, Paul-Emile Labeyrie¹, Laurent Derex^2,3, Marc Hermier¹, Leila Chamard¹, Lise-Prune Berner¹, Roxana Ameli¹, Yves Berthezène^1,4, Francis Turjman¹, Norbert Nighoghossian^3,4 and Tae-Hee Cho^3,4*

• ¹Department of Neuroradiology, Université Lyon 1, Hospices Civils de Lyon, Lyon, France
• ²Health Information Department, HESPER EA7425, Université Lyon 1, Hospices Civils de Lyon, Lyon, France
• ³Department of Stroke Medicine, Université Lyon 1, Hospices Civils de Lyon, Lyon, France
• ⁴CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Lyon, France

Introduction: Randomized trials (RT) have recently validated the superiority of thrombectomy over standard medical care, including intravenous thrombolysis (IVT). However, data on their impact on routine clinical care remains scarce.

Methods: Using a prospective observational registry, we assessed: (1) the clinical and radiological characteristics of all consecutive patients treated with thrombectomy; (2) the outcome of all patients with M1 occlusion (treated with thrombectomy or IVT alone). Two periods were compared: before (2013–2014) and after (2015–2016) the publication of RT.

Results: Endovascular procedures significantly increased between the two periods (N = 82 vs. 314, p < 0.0001). In 2015–2016, patients were older (median [IQR]: 69 [57-80]; vs. 66 [53-74]; p = 0.008), had shorter door-to-clot times (69 [47-95]; vs. 110 [83-155]; p < 0.0001) resulting in a trend toward shorter delay from symptom onset to reperfusion (232 [185-300]; vs. 250 [200-339]; p = 0.1), with higher rates of reperfusion (71 vs. 48%; p = 0.0001). Conversely, no significant differences in baseline NIHSS scores, ASPECTS, delay to IVT or intracranial hemorrhage were found. In 2015–2016, patients with M1 occlusion were treated with thrombectomy more often than in 2013–2014 (87 vs. 32%, respectively; p < 0.0001), with a significant improvement in clinical outcome (shift analysis, lower modified Rankin scale scores: OR = 1.68; 95% CI: 1.10–2.57; p = 0.017).

Conclusion: Following the publication of RT, thrombectomy was rapidly implemented with significant improvements in intrahospital delay and reperfusion rates. Treatment with thrombectomy increased with better clinical outcomes in patients with M1 occlusion.

Introduction

In 2013, the future of endovascular therapy (EVT) in acute ischemic stroke was uncertain, as three consecutive randomized trials failed to demonstrate the superiority of thrombectomy combined with intravenous thrombolysis (IVT) over IVT alone (1–3). Subsequent trials have since established the effectiveness of EVT for patients with large vessel occlusions who were suitably selected by cerebral and arterial imaging (4–11).

Preliminary reports from monocentric (12, 13) or multicentric (14, 15) studies indicate that EVT seems applicable in the “real” world of clinical practice, with similar results to those of controlled trials. Still, little data is available on how systems of care have started to adapt to this paradigm shift in acute stroke therapy. A single study recently reported on the increasing EVT case volumes across the Unites States since the publication of the positive trials (16). The extent to which EVT use has evolved after the pivotal trials and its impact on local practices need to be considered to plan further quality improvement efforts, both within comprehensive stroke centers (CSC, i.e., EVT-capable hospitals) and beyond.

Our institution is the only CSC serving the greater Lyon metropolitan area (population: 2.3 million), treating ~1,600 ischemic stroke patients each year (Figure 1). Prior to the publication of the first positive trial (4), EVT was not considered as standard care, and thus was not systematically considered for patients with proximal intracranial occlusions. Thereafter, local processes were modified to implement thrombectomy in all eligible patients referred to our CSC. Our objective was to assess the effects of this major shift in our reperfusion strategy by comparing two periods: before (January 1st 2013–December 31st 2014) and after (January 1st 2015–December 31st 2016) the publication of the first positive EVT trial. Specifically, we first compared the typology of all consecutive EVT cases (e.g., number of procedures, baseline clinical and radiological characteristics) to assess the development of EVT within our institution. Secondly, we compared the outcome of all patients with M1 occlusion who underwent a revascularization procedure (IVT and/or EVT).