Analysis of early efficacy and safety of endovascular therapy for acute mild ischemic stroke with large vessel occlusion

doi:10.3969/j.issn.1674-8115.2023.10.007

Abstract

Abstract:

Objective ·To investigate the early efficiency and safety of endovascular therapy (EVT) for patients with acute mild ischemic stroke with large vessel occlusion (LVO-MIS). Methods ·A total of 31 patients with LVO-MIS who received emergency EVT-assisted standard medical treatment at the Green Channel of Stroke in Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine from June 2016 to October 2022 were retrospectively included as endovascular therapy group (EVT group), and 32 LVO-MIS patients who only received standard medical treatment in the same period were selected as the control group. General clinical data and parameters related to EVT of the two groups were collected. The primary outcome was early efficacy, that is, the NIHSS at seventh day after treatment (d7NIHSS) score decreased by ≥3 points or directly to 0 points from baseline NIHSS score. Secondary outcomes included successful revascularization of blood vessels and early neurological deterioration (END), and safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality. The primary and secondary outcomes of the two groups of patients were analyzed to evaluate the early efficiency of EVT, and the safety evaluation indicators of the two groups of patients were analyzed to evaluate the safety of EVT. Kruskal-Wallis H test was used to analyze the NIHSS scores of 24 patients in the EVT group who underwent EVT before and after treatment. Results ·There was no statistically significant difference in the general clinical data between the two groups, as well as parameters related to EVT such as occlusion site, and onset-to-admission time. The baseline NIHSS score of the EVT group [5.0 (3.0, 5.0) points] was higher than that of the control group [3.5 (2.0, 5.0) points] (P=0.001), and their d7NIHSS score [1.0 (0, 3.0) points] was lower than that of the control group [2.0 (1.0, 5.8) points] (P=0.040). A total of 24 patients (38.1%) in the two groups achieved early efficacy, including 16 cases in the EVT group and 8 cases in the control group; and the early efficacy rate of the EVT group was higher than that of the control group (χ²=4.729, P=0.030). The END rate in the EVT group was lower than that in the control group (χ² =6.097, P=0.014), and there were 29 cases (93.5%) in the EVT group of patients whose blood vessels were successfully reopened. There was no statistically significant difference in sICH rate and mortality rate between the two groups. In the EVT group, there was a statistically significant difference (H=16.997, P=0.000) among the baseline NIHSS scores [5.0 (3.0, 5.0) points] of 24 patients, postoperative 24hNIHSS score [2.0 (0.3, 3.8) points] and d7NIHSS scores [1.0 (0, 2.8) points]. Conclusion ·EVT is safe and effective in treating LVO-MIS, and the early efficacy rate of EVT is superior to standard medicine treatment, with a lower rate of END and no increased risk of sICH.

Key words: mild ischemic stroke, large vessel occlusion (LVO), endovascular therapy (EVT), early neurological deterioration (END)

CLC Number:

R743.3

NI Ruilong, ZHAO Fei, CAO Li, DENG Jiangshan. Analysis of early efficacy and safety of endovascular therapy for acute mild ischemic stroke with large vessel occlusion[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(10): 1268-1273.

Figures/Tables 3

TrendMD

References 32

1	DARGAZANLI C, ARQUIZAN C, GORY B, et al. Mechanical thrombectomy for minor and mild stroke patients harboring large vessel occlusion in the anterior circulation: a multicenter cohort study[J]. Stroke, 2017, 48(12): 3274-3281.
2	HELDNER M R, CHALOULOS-IAKOVIDIS P, PANOS L, et al. Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score[J]. J Neurol, 2020, 267(6): 1651-1662.
3	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组, 中华医学会神经病学分会神经血管介入协作组. 中国急性缺血性卒中早期血管内介入诊疗指南2022[J]. 中华神经科杂志, 2022, 55(6): 565-580.
	Chinese Society of Neurology, Chinese Stroke Society, Neurovascular Intervention Group of Chinese Society of Neurology Chinese. Chinese guidelines for the endovascular treatment of acute ischemic stroke 2022[J]. Chin J Neurol, 2022, 55(6): 565-580.
4	POWERS W J, DERDEYN C P, BILLER J, et al. 2015 American heart association/American stroke association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American heart association/American stroke association[J]. Stroke, 2015, 46(10): 3020-3035.
5	SARRAJ A, HASSAN A, SAVITZ S I, et al. Endovascular thrombectomy for mild strokes: how low should we go?[J]. Stroke, 2018, 49(10): 2398-2405.
6	MANNO C, DISANTO G, BIANCO G, et al. Outcome of endovascular therapy in stroke with large vessel occlusion and mild symptoms[J]. Neurology, 2019, 93(17): e1618-e1626.
7	DOBROCKY T, PIECHOWIAK E I, VOLBERS B, et al. Treatment and outcome in stroke patients with acute M2 occlusion and minor neurological deficits[J]. Stroke, 2021, 52(3): 802-810.
8	HAUSSEN D C, LIMA F O, BOUSLAMA M, et al. Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts[J]. J Neurointerv Surg, 2018, 10(4): 325-329.
9	王桂芳, 杨晓倩, 肖以磊, 等. 血管内机械取栓治疗大血管闭塞性轻型脑卒中的安全性和有效性分析[J]. 中华神经医学杂志, 2020, 19(7): 711-714.
	WANG G F, YANG X Q, XIAO Y L, et al. Safety and efficacy of mechanical thrombectomy in minor stroke with large vessel occlusion[J]. Chin J Neuromed, 2020, 19(7): 711-714.
10	ALBERS G W, MARKS M P, KEMP S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging[J]. N Engl J Med, 2018, 378(8): 708-718.
11	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志, 2018, 51(9): 666-682.
	Chinese Society of Neurology, Chinese Stroke Society. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2018[J]. Chin J Neurol, 2018, 51(9): 666-682.
12	ZAIDAT O O, YOO A J, KHATRI P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement[J]. Stroke, 2013, 44(9): 2650-2663.
13	陈松, 王驰, 王伟, 等. 急性颅内前循环大血管闭塞血管内治疗再通后早期神经功能恶化的影响因素分析[J]. 中国脑血管病杂志, 2022, 19(2): 73-78, 108.
	CHEN S, WANG C, WANG W, et al. Risk factors of early neurological deterioration after endovascular therapy recanalization for acute intracranial anterior circulation large vessel occlusion[J]. Chinese Journal of Cerebrovascular Diseases, 2022, 19(2): 73-78, 108.
14	SENERS P, BEN HASSEN W, LAPERGUE B, et al. Prediction of early neurological deterioration in individuals with minor stroke and large vessel occlusion intended for intravenous thrombolysis alone[J]. JAMA Neurol, 2021, 78(3): 321-328.
15	HACKE W, KASTE M, BLUHMKI E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke[J]. N Engl J Med, 2008, 359(13): 1317-1329.
16	SALEEM Y, NOGUEIRA R G, RODRIGUES G M, et al. Acute neurological deterioration in large vessel occlusions and mild symptoms managed medically[J]. Stroke, 2020, 51(5): 1428-1434.
17	WANG G F, ZHAO X, LIU S P, et al. Efficacy and safety of mechanical thrombectomy for acute mild ischemic stroke with large vessel occlusion[J]. Med Sci Monit, 2020, 26: e926110.
18	TURC G, BHOGAL P, FISCHER U, et al. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke[J]. J Neurointerv Surg, 2019, 11(6): 535-538.
19	DA ROS V, CORTESE J, CHASSIN O, et al. Thrombectomy or intravenous thrombolysis in patients with NIHSS of 5 or less?[J]. J De Neuroradiol, 2019, 46(4): 225-230.
20	YANG P, ZHANG Y, ZHANG L, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke[J]. N Engl J Med, 2020, 382(21): 1981-1993.
21	TONG X, WANG Y L, FIEHLER J, et al. Thrombectomy versus combined thrombolysis and thrombectomy in patients with acute stroke: a matched-control study[J]. Stroke, 2021, 52(5): 1589-1600.
22	BROEG-MORVAY A, MORDASINI P, BERNASCONI C, et al. Direct mechanical intervention versus combined intravenous and mechanical intervention in large artery anterior circulation stroke: a matched-pairs analysis[J]. Stroke, 2016, 47(4): 1037-1044.
23	BHATIA R, HILL M D, SHOBHA N, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action[J]. Stroke, 2010, 41(10): 2254-2258.
24	刘丽萍, 陈玮琪, 段婉莹, 等. 中国脑血管病临床管理指南(节选版): 缺血性脑血管病临床管理[J]. 中国卒中杂志, 2019, 14(7): 709-726.
	LIU L P, CHEN W Q, DUAN W Y, et al. Chinese stroke association guidelines for clinical management of cerebrovascular disorders (excerpts): clinical management of ischemic cerebrovascular disorders[J]. Chinese Journal of Stroke, 2019, 14(7): 709-726.
25	ZHONG W S, ZHOU Y, ZHANG K M, et al. Minor non-disabling stroke patients with large vessel severe stenosis or occlusion might benefit from thrombolysis[J]. Brain Sci, 2021, 11(7): 945.
26	LAU H L, GARDENER H, COUTTS S B, et al. Radiographic characteristics of mild ischemic stroke patients with visible intracranial occlusion: the INTERRSeCT study[J]. Stroke, 2022, 53(3): 913-920.
27	霍晓川, 高峰. 急性缺血性卒中血管内治疗中国指南2018[J]. 中国卒中杂志, 2018, 13(7): 706-729.
	HUO X C, GAO F. Chinese guideline for endovascular treatment of acute ischemic stroke 2018[J]. Chinese Journal of Stroke, 2018, 13(7): 706-729.
28	孙瑄, 杨明, 余泽权, 等. 症状性颅内动脉粥样硬化性狭窄血管内治疗中国专家共识2022[J]. 中国卒中杂志, 2022, 17(8): 863-888.
	SUN X, YANG M, YU Z Q, et al. Chinese experts consensus on endovascular treatment for symptomatic intracranial atherosclerotic stenosis 2022[J]. Chinese Journal of Stroke, 2022, 17(8): 863-888.
29	SUN L L, ZHANG J P, SONG Y, et al. Safety and efficacy of tirofiban in rescue treatment for acute intracranial intraprocedural stent thrombosis[J]. Front Neurol, 2020, 11: 492.
30	RESCUE BT Trial Investigators, QIU Z M, LI F L, et al. Effect of intravenous tirofiban vs placebo before endovascular thrombectomy on functional outcomes in large vessel occlusion stroke: the RESCUE BT randomized clinical trial[J]. JAMA, 2022, 328(6): 543-553.
31	SLAWSKI D, HEIT J J. Treatment challenges in acute minor ischemic stroke[J]. Front Neurol, 2021, 12: 723637.
32	CAMPBELL B C, CHRISTENSEN S, TRESS B M, et al. Failure of collateral blood flow is associated with infarct growth in ischemic stroke[J]. J Cereb Blood Flow Metab, 2013, 33(8): 1168-1172.

Item	EVT group (n=31)	Control group (n=32)	P value
Age/year	67.8±14.3	66.6±14.7	0.483
Male/n(%)	24 (77.4)	28 (87.5)	0.292
Smoking^a/n(%)	10 (32.3)	10 (31.3)	0.932
Drinking^a/n(%)	8 (25.8)	8 (25.0)	0.941
Medical history^b/n(%)
Hypertension	19 (61.3)	25 (78.1)	0.146
Diabetes	8 (25.8)	8 (25.0)	0.941
Atrial fibrillation	12 (38.7)	7 (21.9)	0.146
Ischemic stroke or TIA	5 (16.1)	10 (31.3)	0.159
Coronary heart disease	1 (3.2)	4 (12.5)	0.173
Occlusion site/n(%)
ICA	5 (16.1)	7 (21.9)	0.561
MCA (M1)	21 (67.7)	16 (50.0)	0.153
MCA (M2)	2 (6.5)	2 (6.3)	0.974
VB/BA	3 (9.7)	7 (21.9)	0.185
Baseline NIHSS score/score	5.0 (3.0, 5.0)	3.5 (2.0, 5.0)	0.001
Onset-to-admission time/min	230 (70, 222)	270 (86, 436)	0.209

Item	EVT group (n=31)	Control group (n=32)	P value
Age/year	67.8±14.3	66.6±14.7	0.483
Male/n(%)	24 (77.4)	28 (87.5)	0.292
Smoking^a/n(%)	10 (32.3)	10 (31.3)	0.932
Drinking^a/n(%)	8 (25.8)	8 (25.0)	0.941
Medical history^b/n(%)
Hypertension	19 (61.3)	25 (78.1)	0.146
Diabetes	8 (25.8)	8 (25.0)	0.941
Atrial fibrillation	12 (38.7)	7 (21.9)	0.146
Ischemic stroke or TIA	5 (16.1)	10 (31.3)	0.159
Coronary heart disease	1 (3.2)	4 (12.5)	0.173
Occlusion site/n(%)
ICA	5 (16.1)	7 (21.9)	0.561
MCA (M1)	21 (67.7)	16 (50.0)	0.153
MCA (M2)	2 (6.5)	2 (6.3)	0.974
VB/BA	3 (9.7)	7 (21.9)	0.185
Baseline NIHSS score/score	5.0 (3.0, 5.0)	3.5 (2.0, 5.0)	0.001
Onset-to-admission time/min	230 (70, 222)	270 (86, 436)	0.209

Outcome	EVT group (n=31)	Control group (n=32)	χ² value	P value
Primary outcome/n(%)
Early efficiency	16 (51.6)	8 (25.0)	4.729	0.030
Secondary outcome/n(%)
mTICI 2b-3	29 (93.5)	6^① (46.2)^②	13.089	0.000
END	1 (3.2)	8 (25.0)	6.097	0.014
Safety outcome
sICH	1 (3.2)	1 (3.1)	0.001	0.982
Death in hospital	0	0	‒	‒

Outcome	EVT group (n=31)	Control group (n=32)	χ² value	P value
Primary outcome/n(%)
Early efficiency	16 (51.6)	8 (25.0)	4.729	0.030
Secondary outcome/n(%)
mTICI 2b-3	29 (93.5)	6^① (46.2)^②	13.089	0.000
END	1 (3.2)	8 (25.0)	6.097	0.014
Safety outcome
sICH	1 (3.2)	1 (3.1)	0.001	0.982
Death in hospital	0	0	‒	‒

[1]	DONG Haiping, XIE Haiyi, MA Xiaoxiao, WANG Zhenhong. Mechanism of blood-brain barrier damage caused by the inhibition of Wnt7/β-catenin pathway induced by endoplasmic reticulum stress in cerebrovascular endothelial cells after stroke [J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(7): 829-838.
[2]	JIANG Wenqun, HOU Pinpin, CHEN Yan, JIA Feng, ZHANG Xiaohua, GAO Li, HU Qin. Characteristics and clinical significance of serum renalase in patients with acute ischemic stroke [J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(1): 29-35.
[3]	WEI Xuemin, GAO Chengjin. Research progress of clinical application of ASPECT score in acute ischemic stroke [J]. Journal of Shanghai Jiao Tong University (Medical Science), 2022, 42(7): 919-924.
[4]	Aiyong YU, Yingchun ZHAO, Xiaochun PAN, Kegui ZHOU, Yuwu ZHAO, Lei GU. Characteristics of cerebral perfusion in patients with limb shaking-transient ischemic attacks with different blood pressure variations [J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2022, 42(2): 178-184.
[5]	Xu-guang CHEN, Sheng-yi SHI, Lan HU, Yu CHEN, Yi-ming LU, Jing YE. Evaluative value of plasma fibrin degradation product in early prognosis of patients with hemorrhagic stroke [J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(5): 612-616.
[6]	Xiu-ying LIU, Rui-fang LAN. Correlation between quantitative electroencephalogram features and CT perfusion imaging parameters in acute ischemic stroke [J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(1): 62-65.
[7]	LIU Xiu-ying, LAN Rui-fang. Correlation between quantitative electroencephalogram features and CT perfusion imaging parameters in patients with acute ischemic stroke [J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 0, (): 1-5.
[8]	LIU Yi-sheng1, ZHAN Yan-li2, PAN Hui1, YIN Jia-wen1, HU Yue1, CAI Xue-li2#, LIU Jian-ren1#. Comparison of outcomes after thrombectomy in patients with embolic stroke of undetermined source and cardiogenic stroke [J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2020, 40(9): 1270-1276.
[9]	HUANG Ting-ting, LI Yan, ZHANG Yue-man, ZHOU Na-ying, FAN Ren-hui, LI Pei-ying. Two-photon in vivo imaging of blood brain barrier injury in the ultra-early stage of cerebral ischemic stroke [J]. , 2019, 39(9): 998-.
[10]	ZHUANG Mei-ting, HE Xin-wei, ZHAO Rong, YIN Jia-wen, HU Yue, LIU Jian-ren. Correlation between plasma brain natriuretic peptide and functional outcome after intravenous thrombolysis in patients with acute ischemic stroke [J]. , 2019, 39(9): 1065-.
[11]	HE Hong1, 2, LIU Yi-sheng1, ZHAO Rong1, LI Ge-fei1, SHI Yan-hui1, LI Yi3, LIU Jian-ren1. Impact of multiple thrombectomy on outcomes of patients with acute ischemic stroke [J]. , 2019, 39(7): 764-.
[12]	ZHANG Cui-ping, OUYANG Xiao-chun, YU Xiao-li, XIONG Wen-juan, WANG Yan-qiu, MA Yao. Relationship between glomerular filtration rate and acute ischemic stroke in middle-aged and elderly population [J]. , 2019, 39(1): 65-.
[13]	WU Yi-lan, LI Ge-fei, SHI Yan-hui, HE Xin-wei, ZHAO Ying, ZHAO Rong, LIU Jian-ren. Detection of hypothalamic infarction in intraluminal middle cerebral artery occlusion model ratDWI scanning [J]. , 2018, 38(8): 894-.
[14]	ZHU Yu-ping, FU Yi, LIU Gui-dong, et al. Correlation of serum thromboxane A₂ and cerebral infarction [J]. , 2009, 29(9): 1077-.
[15]	CHEN Ying, LI Yan-sheng. Effects of gender on post-stroke aphasia [J]. , 2009, 29(8): 978-.