Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR)

Abstract

Background and purpose: Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone.

Methods: Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2).

Results: A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28).

Conclusions: Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.

Trial registration: ClinicalTrials.gov NCT04167527.

Keywords: minor stroke; stroke; thrombectomy; thrombolysis.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Katharina Feil received funding for research from Boehringer Ingelheim and speaker honoraria from Pfizer outside of this study. Marius Matusevicius, Moriz Herzberg, Steffen Tiedt, Clemens Küpper, Johannes Wischmann, Sonja Schönecker, Annerose Mengel, Jennifer Sartor‐Pfeiffer, Konstantin Dimitriadis, Katharina Berger and Marianne Dieterich report no disclosures. Thomas Liebig consults for Stryker Neurovascular GmbH and has received speaker honoraria from Pfizer, Covidien, Phenox and Microvention, outside of this study. Michael Mazya holds a position of Research and Network Executive of SITS International. Niaz Ahmed is the Chairman of SITS International, which receives grants described under funding and has received speaker honoraria from Boehringer Ingelheim. Lars Kellert has received funding for travel or speaker honoraria from Bayer Vital, Boehringer Ingelheim, Bristol‐Meyer‐Squibb, Daiichi Sankyo and Pfizer, outside of this study, and funding for research from Boehringer Ingelheim.

© 2022 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.

Figures

FIGURE 1

Flowchart for the propensity‐score matched analysis of large vessel occlusion patients with minor stroke symptoms from the German Stroke Registry–Endovascular Treatment (GSR‐ET) and the Safe Implementation of Treatments in Stroke–International Stroke Thrombolysis Register (SITS‐ISTR). EVT, endovascular thrombectomy; IQR, interquartile range; IVT, intravenous thrombolysis; MT, mechanical thrombectomy; n, number; NIHSS, National Institute of Health Stroke Scale; pmRS, premorbid modified Rankin Scale; PSM, propensity‐score matching

FIGURE 2

Outcome at follow‐up comparing (a) German Stroke Registry–Endovascular Treatment (GSR‐ET; endovascular thrombectomy [EVT] and intravenous thrombolysis [IVT]) patients versus Safe Implementation of Treatments in Stroke–International Stroke Thrombolysis Register (SITS‐ISTR; IVT‐only) patients and (b) GSR‐ET (EVT ± IVT) patients versus SITS‐ISTR (IVT‐only) patients. Abbreviations: EVT, endovascular thrombectomy; IQR, interquartile range; IVT, intravenous thrombolysis; LVO, large vessel occlusion; n, number; pmRS, premorbid modified Rankin Scale [Colour figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Binary logistic regression for good outcome (modified Rankin scale [mRS] score 0–2) at follow‐up for (a) in the matched population (German Stroke Registry–Endovascular Treatment [GSR‐ET] and Safe Implementation of Treatments in Stroke–International Stroke Thrombolysis Register [SITS‐ISTR]; n = 544, propensity‐score matching of minor strokes with large vessel occlusion (LVO) comparing GSR‐ET (endovascular thrombectomy [EVT] and intravenous thrombolysis [IVT]) versus SITS‐ISTR [IVT‐only] patients) and (b) in the matched population (GSR‐ET and SITS‐ISTR; n = 1248, propensity‐score matching of minor strokes with LVO comparing GSR‐ET (EVT with or without IVT) to SITS‐ISTR (IVT‐only) patients. CI, confidence interval; ICH, intracerebral hemorrhage; NIHSS, National Institute of Health Stroke Scale; OR, odds ratio; pmRS, premorbid modified Rankin scale