Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke The TOPMOST Study

Meyer, Lukas; Stracke, Christian Paul; Jungi, Noel; Wallocha, Marta; Broocks, Gabriel; Sporns, Peter B.; Maegerlein, Christian; Dorn, Franziska; Zimmermann, Hanna; Naziri, Weis; Abdullayev, Nuran; Kabbasch, Christoph; Behme, Daniel; Jamous, Ala; Maus, Volker; Fischer, Sebastian; Moehlenbruch, Markus; Weyland, Charlotte Sabine; Langner, Soenke; Meila, Dan; Miszczuk, Milena; Siebert, Eberhard; Lowens, Stephan; Krause, Lars Udo; Yeo, Leonard L. L.; Tan, Benjamin Yong-Qiang; Anil, Gopinathan; Gory, Benjamin; Galvan, Jorge; Arteaga, Miguel Schueller; Navia, Pedro; Raz, Eytan; Shapiro, Maksim; Arnberg, Fabian; Zelenak, Kamil; Martinez-Galdamez, Mario; Fischer, Urs; Kastrup, Andreas; Roth, Christian; Papanagiotou, Panagiotis; Kemmling, Andre; Gralla, Jan; Psychogios, Marios-Nikos; Andersson, Tommy; Chapot, Rene; Fiehler, Jens; Kaesmacher, Johannes und Hanning, Uta (2021): Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke The TOPMOST Study. In: Jama Neurology, Bd. 78, Nr. 4: S. 434-444

Abstract

This case-control study analyzes the clinical, functional, and safety outcomes associated with endovascular therapy for patients with posterior circulation distal, medium vessel occlusion. Question Is mechanical thrombectomy for ischemic stroke attributed to primary distal occlusion of the posterior cerebral artery of the P2 or P3 segment safe, technically feasible, and associated with clinical benefits compared with standard medical treatment alone? Findings In this case-control study of 184 patients, endovascular treatment appeared to be safe (symptomatic intracerebral hemorrhage) and technically feasible (proportion of successful recanalization) and showed early clinical treatment benefits on the National Institutes of Health Stroke Scale, compared with standard medical treatment alone. Meaning Results of this study suggest that, among patients who experienced stroke attributed to primary distal occlusion of the posterior cerebral artery of the P2 or P3 segment, mechanical thrombectomy is a reasonable, safe and technically feasible therapy option. Importance Clinical evidence of the potential treatment benefit of mechanical thrombectomy for posterior circulation distal, medium vessel occlusion (DMVO) is sparse. Objective To investigate the frequency as well as the clinical and safety outcomes of mechanical thrombectomy for isolated posterior circulation DMVO stroke and to compare them with the outcomes of standard medical treatment with or without intravenous thrombolysis (IVT) in daily clinical practice. Design, Setting, and Participants This multicenter case-control study analyzed patients who were treated for primary distal occlusion of the posterior cerebral artery (PCA) of the P2 or P3 segment. These patients received mechanical thrombectomy or standard medical treatment (with or without IVT) at 1 of 23 comprehensive stroke centers in Europe, the United States, and Asia between January 1, 2010, and June 30, 2020. All patients who met the inclusion criteria were matched using 1:1 propensity score matching. Interventions Mechanical thrombectomy or standard medical treatment with or without IVT. Main Outcomes and Measures Clinical end point was the improvement of National Institutes of Health Stroke Scale (NIHSS) scores at discharge from baseline. Safety end point was the occurrence of symptomatic intracranial hemorrhage and hemorrhagic complications were classified based on the Second European-Australasian Acute Stroke Study (ECASSII). Functional outcome was evaluated with the modified Rankin Scale (mRS) score at 90-day follow-up. Results Of 243 patients from all participating centers who met the inclusion criteria, 184 patients were matched. Among these patients, the median (interquartile range [IQR]) age was 74 (62-81) years and 95 (51.6%) were female individuals. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%). At discharge, the mean NIHSS score decrease was -2.4 points (95% CI, -3.2 to -1.6) in the standard medical treatment cohort and -3.9 points (95% CI, -5.4 to -2.5) in the mechanical thrombectomy cohort, with a mean difference of -1.5 points (95% CI, 3.2 to -0.8;P = .06). Significant treatment effects of mechanical thrombectomy were observed in the subgroup of patients who had higher NIHSS scores on admission of 10 points or higher (mean difference, -5.6;95% CI, -10.9 to -0.2;P = .04) and in the subgroup of patients without IVT (mean difference, -3.0;95% CI, -5.0 to -0.9;P = .005). Symptomatic intracranial hemorrhage occurred in 4 of 92 patients (4.3%) in each treatment cohort. Conclusions and Relevance This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT.

• Dokumententyp: Zeitschriftenartikel
• Fakultät: Medizin
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• ISSN: 2168-6149
• Sprache: Englisch