Thrombectomy vs Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort. Annals of neurology Sarraj, A., Albers, G. W., Blasco, J., Arenillas, J. F., Ribo, M., Hassan, A. E., Perez de la Ossa, N., Wu, T. Y., Cardona Portela, P., Abraham, M. G., Chen, M., Maali, L., Kleinig, T. J., Cordato, D., Wallace, A. N., Schaafsma, J. D., Sangha, N., Gibson, D. P., Blackburn, S. L., De Lera Alfonso, M., Pujara, D., Shaker, F., McCullough-Hicks, M. E., Moreno Negrete, J. L., Renu, A., Beharry, J., Cappelen-Smith, C., Rodriguez-Esparragoza, L., Olive-Gadea, M., Requena, M., Almaghrabi, T., Mendes Pereira, V., Sitton, C., Martin-Schild, S., Song, S., Ma, H., Churilov, L., Mitchell, P. J., Parsons, M. W., Furlan, A., Grotta, J. C., Donnan, G. A., Davis, S. M., Campbell, B. C., PERFECT-MILD Collaborators 2022


OBJECTIVE: To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits, stratified by perfusion imaging mismatch.METHODS: Pooled cohort of patients with NIHSS<6 and ICA, M1, M2 occlusions from EXTEND-IA, EXTEND-IA-TNK I/II RCTs and prospective data from 15 EVT centers from 10/2010 to 4/2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary endovascular thrombectomy (EVTpri ) were compared to those who received primary MM (MMpri ), including those who deteriorated and received rescue EVT, in overall and PS matched cohorts. Patients were stratified by target mismatch (mismatch-ratio=1.8 and mismatch-volume=15cc). Primary outcome was functional independence (90-day mRS:0-2); Secondary outcomes included safety (sICH, neurological worsening, and mortality).RESULTS: Of 540 patients, 286/540(53%) received EVTpri and demonstrated larger critically hypoperfused tissue (Tmax>6s) volumes of (64[26-96]mL vs MMpri :40[14-76]mL, p<0·001) and higher presentation NIHSS (4(2-5) vs MMpri :3(2-4), p<0·001). Functional independence was similar (EVTpri :77·4% vs MMpri :75.6%, aOR:1.29,95%CI:0.82-2.03,p=0.27). EVT had worse safety: sICH (EVTpri :8.8% vs MMpri :1.3%, p<0.001) and neurological worsening (EVTpri :19.6% vs MMpri :6.7%, p<0.001). In 414(76.7%) with target mismatch, EVT was associated with improved functional independence (EVTpri :77·4% vs MMpri :72.7%, aOR:1.68, 95%CI:1.01-2.81,p=0.048), whereas, there was a trend toward less favorable outcomes with primary EVT (EVTpri :77·4% vs MMpri :83.3%, aOR:0.39,95%CI:0.12-1.34,p=0.13) without target mismatch, (pinteraction =0.06). Similar findings were observed in a PS matched subpopulation.INTERPRETATION: Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. This article is protected by copyright. All rights reserved.

View details for DOI 10.1002/ana.26418

View details for PubMedID 35599458