Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

When all that comes from research is suggestions for further research you need better mentors and senior researchers. We should at least get a tentative protocol that can be verified with that further research. This was useless.

Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis 

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Meredeth Zotter, Eike I. Piechowiak, Rupashani Balasubramaniam, ...

First Published March 11, 2021 Research Article 

https://doi.org/10.1177/1756286421999017

Article information 

 

Abstract

Background and aims:

To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy.

Methods:

We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis).

Results:

The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission (p = 0.030). They were more frequently treated with stent retrievers (p = 0.007), but the median number of stent retriever attempts was lower (p = 0.016) and fewer had permanent stent placements (p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift (p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift (p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044).

Conclusion:

We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

Keywords all cerebrovascular disease/stroke, CT, MR

Introduction

In patients with acute ischaemic stroke, the immediate aim is to restore blood flow to salvageable brain tissue. The long-term aim is to improve outcome by reducing disability and mortality. Effective options for reperfusion therapy are intravenous alteplase, intravenous tenecteplase and endovascular therapy (±intravenous thrombolysis). Endovascular therapy (±intravenous thrombolysis) has the potential to improve 3-month outcome in patients with acute ischaemic stroke and large vessel occlusion in the anterior circulation if they have no contraindications and can be treated within a few hours of stroke onset.^1,2

Two of the most common stroke aetiologies involve cardioembolism and large-artery atherosclerosis.^3,4 Large-artery atherosclerosis is typified by a significant narrowing of extra- or intracranial brain-supplying arteries, potentially leading to local vessel occlusion, embolism and/or, less frequently, to haemodynamic impairment.^3,4 Investigation of stroke aetiology is requisite for targeted secondary prevention to reduce recurrence and may support improved outcome in dedicated stroke units.^5,6 Vascular risk factor profiles and other data have been shown to differ between the two stroke aetiologies mentioned above, with acute ischaemic stroke of cardioembolic origin historically being associated with worse outcome.^7–9 Stroke aetiology might influence the outcome of reperfusion.^10,11 However, data on endovascular therapy (±intravenous thrombolysis) that include comparison of stroke aetiology are scarce.^9,11–13

The aim of this study was to compare patients with cardioembolism versus large-artery atherosclerosis as determined stroke aetiology and to investigate whether stroke aetiology has an impact on reperfusion and outcome in patients with acute ischaemic stroke and large vessel occlusion in anterior circulation treated with endovascular therapy, including intra-arterial thrombolysis and/or mechanical thrombectomy (±intravenous thrombolysis).

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