Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient‐Level Analysis from the EXTEND‐IA Trials, INSPIRE , and SELECT Studies

Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient‐Level Analysis from the EXTEND‐IA Trials, INSPIRE , and SELECT Studies · SciRah

^aCase Western Reserve University, Neurology Cleveland OH USA
^bUniversity Hospitals Cleveland Medical Center Cleveland OH USA
^cCase Western Reserve University, Neurology, Cleveland, OH, USA
^dUniversity Hospitals Cleveland Medical Center, Cleveland, OH, USA
^eThe University of New South Wales, Neurology Sydney New South Wales Australia
^fThe University of New South Wales, Neurology, Sydney, New South Wales, Australia
^gThe Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
^hThe University of Newcastle Stroke and Brain Injury Center Callaghan New South Wales Australia
ⁱThe Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Neurology, Parkville, Victoria, Australia
^jThe University of Newcastle, Stroke and Brain Injury Center, Callaghan, New South Wales, Australia
^kUniversity of Texas Rio Grande Valley ‐ Valley Baptist Medical Center, Neurology Harlingen TX USA
^lUniversity of Texas Rio Grande Valley - Valley Baptist Medical Center, Neurology, Harlingen, TX, USA
^mUniversity of Kansas Medical Center Kansas City KS USA
ⁿUniversity of Kansas Medical Center, Kansas City, KS, USA
^oChristchurch Hospital, Neurology Christchurch New Zealand
^pChristchurch Hospital, Neurology, Christchurch, New Zealand
^qRoyal Adelaide Hospital, Neurology Adelaide South Australia Australia
^rRoyal Adelaide Hospital, Neurology, Adelaide, South Australia, Australia
^sJohn Hunter Hospital University of Newcastle, Neurology Newcastle New South Wales Australia
^tJohn Hunter Hospital, University of Newcastle, Neurology, Newcastle, New South Wales, Australia
^uHuashan Hospital, Fudan University, Neurology Shanghai China
^vHuashan Hospital, Fudan University, Neurology, Shanghai, China
^wEastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Victoria Australia
^xEastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
^yThe Walter and Eliza Hall Institute of Medical Research Population Health and Immunity Division Parkville Victoria Australia
^zThe Walter and Eliza Hall Institute of Medical Research, Population Health and Immunity Division, Parkville, Victoria, Australia
^aaGold Coast University Hospital, Neurology Southport Queensland Australia
^abGold Coast University Hospital, Neurology, Southport, Queensland, Australia
^acUTHealth McGovern Medical School, Neurosurgery Houston TX USA
^adUTHealth McGovern Medical School, Neurosurgery, Houston, TX, USA
^aeStroke Theme, Florey Institute of Neuroscience and Mental Health University of Melbourne Heidelberg Victoria Australia
^afStroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia
^agUTHealth McGovern Medical School Diagnostic and Interventional Imaging Houston TX USA
^ahUTHealth McGovern Medical School, Diagnostic and Interventional Imaging, Houston, TX, USA
^aiThe Royal Melbourne Hospital University of Melbourne, Radiology Parkville Victoria Australia
^ajThe Royal Melbourne Hospital, University of Melbourne, Radiology, Parkville, Victoria, Australia
^akMemorial Hermann – Texas Medical Center, Neurology Houston TX USA
^alStanford University Medical Center Neurology and Neurological Sciences Stanford CA USA
^amStanford University Medical Center, Neurology and Neurological Sciences, Stanford, CA, USA
✉Corresponding author

Abstract

OBJECTIVE: The objective of this study was to evaluate functional and safety outcomes of endovascular thrombectomy (EVT) versus medical management (MM) in patients with M2 occlusion and examine their association with perfusion imaging mismatch and stroke severity. METHODS: In a pooled, patient-level analysis of 3 randomized controlled trials (EXTEND-IA, EXTEND-and IA-TNK parts 1 and 2) and 2 prospective nonrandomized studies (INSPIRE and SELECT), we evaluated EVT association with 90-day functional independence (modified Rankin Scale [mRS] = 0-2) in isolated M2 occlusions as compared to medical management overall and in subgroups by mismatch profile status and stroke severity. RESULTS: We included 517 patients (EVT = 195 and MM = 322), baseline median (interquartile range [IQR]) National Institutes of Health Stroke Scale (NIHSS) was 13 (8-19) in EVT versus 10 (6-15) in MM, p < 0.001. Pretreatment ischemic core did not differ (EVT = 10 [0-24] ml vs MM = 9 [3-21] ml, p = 0.59). Compared to MM, EVT was more frequently associated with functional independence (68.3 vs 61.6%, adjusted odds ratio [aOR] = 2.42, 95% confidence interval [CI] = 1.25-4.67, p = 0.008, inverse probability of treatment weights [IPTW]-OR = 1.75, 95% CI = 1.00-3.75, p = 0.05) with a shift toward better mRS outcomes (adjusted cOR = 2.02, 95% CI:1.23-3.29, p = 0.005), and lower mortality (5 vs 10%, aOR = 0.32, 95% CI = 0.12-0.87, p = 0.025). EVT was associated with higher functional independence in patients with a perfusion mismatch profile (EVT = 70.7% vs MM = 61.3%, aOR = 2.29, 95% CI = 1.09-4.79, p = 0.029, IPTW-OR = 2.02, 1.08-3.78, p = 0.029), whereas no difference was found in those without mismatch (EVT = 43.8% vs MM = 62.7%, p = 0.17, IPTW-OR: 0.71, 95% CI = 0.18-2.78, p = 0.62). Functional independence was more frequent with EVT in patients with moderate or severe strokes, as defined by baseline NIHSS above any thresholds from 6 to 10, whereas there was no difference between groups with milder strokes below these thresholds. INTERPRETATION: In patients with M2 occlusion, EVT was associated with improved clinical outcomes when compared to MM. This association was primarily observed in patients with a mismatch profile and those with higher stroke severity. ANN NEUROL 2022;91:629-639.

TL;DRThe objective of this study was to evaluate functional and safety outcomes of endovascular thrombectomy versus medical management in patients with M2 occlusion and examine their association with perfusion imaging mismatch and stroke severity. (Semantic Scholar)

Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient‐Level Analysis from the EXTEND‐IA Trials, INSPIRE , and SELECT Studies

Abstract

Plain-language summary

Discussion