Thrombectomy may improve functional independence in acute ischemic stroke with medium vessel occlusion

1. In this randomized controlled trial, acute stroke patients with medium-vessel occlusion and moderate-to-severe neurological deficits who received thrombectomy in addition to medical management were more likely to achieve functional independence than those receiving medical management alone.

2. Thrombectomy did not affect overall mortality rate but was associated with higher rates of intracranial hemorrhage. 

Evidence Rating Level: 1 (Excellent)

Study Rundown: Endovascular thrombectomy is commonly utilized in patients with acute stroke caused by large-vessel occlusions. However, clinical benefit has been less clear in those with medium vessel occlusions. Previous trials have reported poor outcomes, though these studies have focused on younger adults with mild neurological deficits. This open-label, randomized controlled trial aimed to elucidate the safety and efficacy of endovascular thrombectomy in stroke patients with medium vessel occlusion and moderate-to-severe deficits. The primary outcome was functional independence after three months; secondary outcomes included quality of life measures and ability to independently ambulate. Primary safety outcomes were symptomatic intracranial hemorrhage and all-cause mortality. It was found that patients receiving thrombectomy achieved functional independence at a rate significantly higher than those patients receiving only medical management. Similarly, excellent outcome was achieved in a greater proportion of the thrombectomy group as compared to control. Symptomatic intracranial hemorrhage, however, occurred approximately twice as frequently in the thrombectomy group versus the control group, although there was no between-group difference in mortality. This study was limited by a population with predominantly atherosclerotic rather than cardioembolic disease, which may limit generalizability to other populations. Additionally, the primary outcome was evaluated using subjective reporting, potentially introducing bias. In summary, among patients with medium vessel occlusion stroke and moderate-to-severe deficits, thrombectomy was associated with improved functional independence outcomes but also a higher risk of symptomatic intracranial hemorrhage. 

Click to read the study in NEJM

Relevant Reading: Endovascular Thrombectomy in Acute Ischemic Stroke

In-Depth [randomized controlled trial]: This open-label randomized controlled trial assessed the safety and efficacy of endovascular thrombectomy for ischemic stroke due to medium-vessel occlusion. Adults in this study were functionally independent prior to the stroke and had moderate-to-severe clinical deficits after the stroke. Eligible patients had a single occlusion of prespecified distal branches of the middle, anterior, or posterior cerebral arteries, as determined by either computed tomographic or magnetic resonance angiography. Patients underwent randomization in a 1:1 ratio to receive either medical management alone or medical management plus endovascular thrombectomy.  A total of 563 patients were included in the primary intention-to-treat analysis. The primary outcome was functional independence as measured by modified Rankin scale. Secondary outcomes included excellent outcome (Rankin score, 0 or 1), independent ambulation, and quality of life. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Successful reperfusion was achieved in nearly 75% of patients receiving thrombectomy. Of patients in the thrombectomy group, 58.6% achieved functional independence as compared to 46.6% of patients in the control group (adjusted rate ratio, 1.24; 95% confidence interval, 1.07 to 1.44; p=0.004). Similarly, an excellent outcome at 90 days was observed more commonly in the thrombectomy group compared to control (48.9% vs. 33.2%; adjusted rate ratio [aRR], 1.47; 95% CI, 1.20 to 1.78), although quality of life scores were not significantly different between groups. There was no significant difference in mortality at 90 days between the two groups (11.1% versus 10.2%; aRR, 1.11; 95% CI, 0.70 to 1.76). However, symptomatic intracranial hemorrhage occurred nearly twice as often in those receiving thrombectomy compared to control (adjusted risk ratio, 2.21; 95% CI, 0.87 to 5.63), as did any radiologically diagnosed intracranial hemorrhage. Overall, thrombectomy was associated with both a greater likelihood of functional independence and a greater risk of intracranial hemorrhage. 

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