Endovascular Versus Medical Management in Distal Medium Vessel Occlusion Stroke: The DUSK Study

Author:

Mohammaden Mahmoud H.123ORCID,Souza Viana Lorena12ORCID,Abdelhamid Hend12ORCID,Olive-Gadea Marta4ORCID,Rodrigo-Gisbert Marc4ORCID,Requena Manuel4ORCID,Martins Pedro N.12ORCID,Matsoukas Stavros5ORCID,Schuldt Braxton R.5ORCID,Fifi Johanna T.5ORCID,Farooqui Mudassir6ORCID,Vivanco-Suarez Juan6ORCID,Ortega-Gutierrez Santiago6ORCID,Klein Piers7ORCID,Abdalkader Mohamad7ORCID,Vigilante Nicholas8ORCID,Siegler James E.8ORCID,Moreira Ferreira Felipe12,Peng Sophia9,Alaraj Ali9ORCID,Haussen Diogo C.12ORCID,Nguyen Thanh N.7ORCID,Nogueira Raul G.10

Affiliation:

1. Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.).

2. Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.).

3. Department of Neurology, Faculty of Medicine, South Valley University, Qena, Egypt (M.H.M.).

4. Department of Neurology, Hospital Universitario Vall d’Hebron, Barcelona, Spain (M.O.-G., M.R.-G., M.R.).

5. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (S.M., B.R.S., J.T.F.).

6. Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., J.V.-S., S.O.-G.).

7. Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (P.K., M.A., T.N.N.).

8. Department of Neurology, Cooper University Medical Center, Camden, NJ (N.V., J.E.S.).

9. Department of Neurosurgery, University of Illinois at Chicago (S.P., A.A.).

10. Department of Neurology, Neurosurgery, University of Pittsburgh Medical Center, PA (R.G.N.).

Abstract

BACKGROUND: Endovascular treatment (EVT) is part of the usual care for proximal vessel occlusion strokes. However, the safety and effectiveness of EVT for distal medium vessel occlusions remain unclear. We sought to compare the clinical outcomes of EVT to medical management (MM) for isolated distal medium vessel occlusions. METHODS: This is a retrospective analysis of prospectively collected data from seven comprehensive stroke centers. Patients were included if they had isolated distal medium vessel occlusion strokes due to middle cerebral artery M3/M4, anterior cerebral artery A2/A3, or posterior cerebral artery P1/P2 segments. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included 90-day good (mRS score, 0–2) and excellent (mRS score, 0–1) outcomes. Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: A total of 321 patients were included in the analysis (EVT, 179; MM, 142; 40.8% treated with intravenous thrombolysis). In the inverse probability of treatment weighting model, there were no significant differences between EVT and MM in terms of the overall degree of disability (mRS ordinal shift; adjusted odds ratio [aOR], 1.25 [95% CI, 0.95–1.64]; P =0.110), rates of good (mRS score, 0–2; aOR, 1.32 [95% CI, 0.97–1.80]; P =0.075) and excellent (aOR, 1.32 [95% CI, 0.94–1.85]; P =0.098) outcomes, or mortality (aOR, 1.20 [95% CI, 0.78–1.85]; P =0.395) at 90 days. The multivariable regression model showed similar findings. Moreover, there was no difference between EVT and MM in rates of symptomatic intracranial hemorrhage in the multivariable regression model (aOR, 0.57 [95% CI, 0.21–1.58]; P =0.277), but the inverse probability of treatment weighting model showed a lower likelihood of symptomatic intracranial hemorrhage (aOR, 0.46 [95% CI, 0.24–0.85]; P =0.013) in the EVT group. CONCLUSIONS: This multicenter study failed to demonstrate any significant outcome differences among patients with isolated distal medium vessel occlusions treated with EVT versus MM. These findings reinforce clinical equipoise. Randomized clinical trials are ongoing and will provide more definite evidence.

Publisher

Ovid Technologies (Wolters Kluwer Health)

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