Clinical effect of successful reperfusion in patients presenting with NIHSS Johannes Kaesmacher  1   2 , Panagiotis Chaloulos-Iakovidis  2 , Leonidas Panos  2 , Pasquale Mordasini  1 , Mirjam R Heldner  2 , Christoph C Kurmann  2 , Patrik Michel  3 , Steven D Hajdu  4 , Marc Ribo  5 , Manuel Requena  5 , Christian Maegerlein  6 , Benjamin Friedrich  6 , Vincent Costalat  7 , Amel Benali  7 , Laurent Pierot  8 , Matthias Gawlitza  8 , Joanna Schaafsma  9 , Vitor Mendes Pereira  10 , Jan Gralla  1 , Urs Fischer  11 Affiliations Expand Affiliations 1 University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland. 2 Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland. 3 Department of Neurology, CHUV Lausanne, Lausanne, Switzerland. 4 Department of Radiology, CHUV Lausanne, Lausanne, Switzerland. 5 Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain. 6 Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany. 7 Department of Neuroradiology, CHU Montpellier, Montpellier, France. 8 Department of Neuroradiology, CHU Reims, Reims, France. 9 Department of Neurology, Toronto Western Hospital, Toronto, ON, Canada. 10 Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada. 11 Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland. urs.fischer@insel.ch. PMID: 30617997 PMCID: PMC6394689 DOI: 10.1007/s00415-018-09172-1 Free PMC article Item in Clipboard

Abstract

Background and purpose: If patients presenting with large vessel occlusions (LVO) and mild symptoms should be treated with endvoascular treatment (EVT) remains unclear. Aims of this study were (1) assessing the safety and technical efficacy of EVT in patients with NIHSS < 8 as opposed to a comparison group of patients presenting with NIHSS ≥ 8 and (2) evaluation of the clinical effect of reperfusion in patients with NIHSS < 8.

Methods: Patients included into the retrospective multicenter BEYOND-SWIFT registry (NCT03496064) were analyzed. Clinical effect of achieving successful reperfusion (defined as modified Thrombolysis in Cerebral Infarction grade 2b/3) in patients presenting with NIHSS < 8 (N = 193) was evaluated using multivariable logistic regression analyses (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI). Primary outcome was excellent functional outcome (modified Rankin Scale, mRS 0-1) at day 90. Safety and efficacy of mechanical thrombectomy in patients with NIHSS < 8 was compared to patients presenting with NIHSS ≥ 8 (N = 1423).

Results: Among patients with NIHSS < 8 (N = 193, 77/193, 39.9% receiving pre-interventional IV-tPA), successful reperfusion was significantly related to mRS 0-1 (aOR 3.217, 95%-CI 1.174-8.816) and reduced the chances of non-hemorrhagic neurological worsening (aOR 0.194, 95%-CI 0.050-0.756) after adjusting for prespecified confounders. In interaction analyses, the relative merits of achieving successful reperfusion were mostly comparable between patients presenting with NIHSS < 8 and NIHSS ≥ 8 as evidenced by non-significantly different aOR. Interventional safety and efficacy metrics were similar between patients with NIHSS < 8 and NIHSS ≥ 8.

Conclusions: Achieving successful reperfusion is beneficial in patients with persisting LVO presenting with NIHSS < 8 and reduces the risk of non-hemorrhagic neurological worsening.

Keywords: Endovascular; Low NIHSS; Mechanical thrombectomy; Mild symptoms; Stroke; Thrombolysis.

Conflict of interest statement

Dr. Fischer is a consultant for Medtronic and Stryker and Co-PI of the SWIFT DIRECT trial (Medtronic). Dr Gralla is a global principal investigator of STAR (Solitaire FR Thrombectomy for Acute Revascularisation), clinical event committee member of the PROMISE study (European Registry on the ACE Reperfusion Catheters and the Penumbra System in the Treatment of Acute Ischemic Stroke; Penumbra), and a principal investigator and consultant for the SWIFT DIRECT study (Medtronic) and receives Swiss National Science Foundation (SNSF) grants for magnetic resonance imaging in stroke. Dr Pierot serves as a consultant for Balt, Microvention, and Penumbra. Dr. Kaesmacher has received travel grants from Pfizer and Stryker and received research grants from the SAMW/Bangerter Foundation and the Swiss Stroke Society. Dr Ribo serves as a consultant for Medtronic, Stryker, Anaconda, Apta Targets, and Perflow Medical and as a speaker for Neuravi. Dr Michel has received funding for speaker honoraria from Boehringer. He has served on scientific advisory boards also for Boehringer. He has received research grants from Bristol-Myers Squibb, Boehringer, and the Swiss Heart Foundation. Dr. Pereira is a consultant for Stryker (SC for DAWN trial), Penumbra (SC for PROMISE study), BALT (proctorship of products unrelated to ischemic stroke), Phenox, Rapid Medical, Neurovasc and receives research a grant from Philips. All other authors declare that there are no conflicts of interest.

Figures

Fig. 1

Study Flow Chart of the BEYOND-SWIFT Registry

Fig. 2

Day 90 Functional Outcome. a Comparison of patients with NIHSS < 8 and patients presenting with NIHSS ≥ 8; b, Patients with NIHSS < 8 dichotomized according to their reperfusion success; NIHSS National Institute of Health Stroke Scale, mRS modified Rankin Scale

Fig. 3

adjusted Odds Ratios of successful reperfusion (TICI2b/3) for various endpoints with strata of admission NIHSS