Endovascular therapy in acute ischemic stroke with poor reperfusion is associated with worse outcomes compared with best medical management: a HERMES substudy.

BACKGROUND

Functional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with poor reperfusion were compared with patients with AIS-LVO treated with best medical management only.

METHODS

Data are from the HERMES collaboration, a patient-level meta-analysis of seven randomized EVT trials. Baseline characteristics and functional outcomes (modified Rankin Scale (mRS) score at 90 days) were compared between patients with poor reperfusion (defined as modified Thrombolysis in Cerebral Infarction Score 0-1 on the final intracranial angiography run as assessed by the central imaging core laboratory) and patients in the control arm with multivariable logistic ordinal logistic regression adjusted for pre-specified baseline variables.

RESULTS

972 of 1764 patients from the HERMES collaboration were included in the analysis: 893 in the control arm and 79 in the EVT arm with final mTICI 0-1. Patients with poor reperfusion who underwent EVT had higher baseline National Institutes of Health Stroke Scale than controls (median 19 (IQR 15.5-21) vs 17 (13-21), P=0.011). They also had worse mRS at 90 days compared with those in the control arm in adjusted analysis (median 4 (IQR 3-6) vs median 4 (IQR 2-5), adjusted common OR 0.59 (95% CI 0.38 to 0.91)). Symptomatic intracranial hemorrhage was not different between the two groups (3.9% vs 3.5%, P=0.75, adjusted OR 0.94 (95% CI 0.23 to 3.88)).

CONCLUSION

Poor reperfusion after EVT was associated with worse outcomes than best medical management, although no difference in symptomatic intracranial hemorrhage was seen. These results emphasize the need for additional efforts to further improve technical EVT success rates.

Informations de copyright

© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.

Déclaration de conflit d'intérêts

Competing interests: JO received consulting fees from Nicolab. SBB receives support from the University of Calgary and is on the data safety and monitoring advisory board of the TESLA study. RVM is a shareholder of Collavidence. MDH received support from Medtronic via a grant to the University of Calgary for the HERMES collaboration (now complete and inactive). He reports additional support from Boehringer Ingelheim to the University of Calgary for the TEMPO-2 trial, from Biogen to the University of Calgary, and from NoNo to the University of Calgary for the ESCAPE-NA1 trial and the ESCAPE-NEXT trial, as well as money from the Canadian Institutes for Health Research for the ESCAPE-NA1 and ESCAPE-NEXT trials, as well as from Alberta Innovates to the University of Calgary for the QuICR Alberta Stroke Program for the ESCAPE-NA1 trial. He additionally reports paid work for the adjudication of clinical trial outcomes from Sun Pharma and Brainsgate. He is on the data safety monitoring board for the RACECAT trial, Oncovir Hiltonel trial, DUMAS trial, ARTESIA trial, and BRAIN-AF trial. He is the president of the Canadian Neurological Sciences Federation and Canadian Stroke Consortium. He has private stocks in Circle Inc and PureWeb Inc. KWM has received grants from the British Heart Foundation, The Stroke Association, and Innovate UK for the ATTEST-2 and TEMPO-2 trials. He has accepted consulting fees from Boehringer-Ingelheim, Abbvie, and Biogen. He has received lecture fees from Boehringer Ingelheim. He is on the data safety and monitoring board of the ARREST trial. PJM has received royalties or licenses from Medtronic and Stryker for institutional research support, and support from Stryker, Medtronic, and Microvention for attending meetings and/or travel. MG has received grants from NoNo, Medtronic, and Cerenovus via the University of Calgary. He has received royalties or licenses from GE Healthcare and Microvention. He has received consulting fees from Microvention, Medtronic, Stryker, and Mentice. He has stock or stock options in Circle Neurovascular.