Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score

Mirjam R Heldner; Panagiotis Chaloulos-Iakovidis; Leonidas Panos; Bastian Volbers; Johannes Kaesmacher; Tomas Dobrocky; Pasquale Mordasini; Marwan El-Koussy; Jan Gralla; Marcel Arnold; Urs Fischer; Heinrich P Mattle; Simon Jung

doi:10.1007/s00415-020-09744-0

Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score

J Neurol. 2020 Jun;267(6):1651-1662. doi: 10.1007/s00415-020-09744-0. Epub 2020 Feb 15.

Affiliations

¹ Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland. mirjam.heldner@insel.ch.
² Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.
³ Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.
⁴ University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.

PMID: 32062782
DOI: 10.1007/s00415-020-09744-0

Abstract

Background: Optimal management of patients with large vessel occlusion (LVO) and low NIHSS score is unknown, which was the aim to investigate in this study.

Methods: This is a retrospective analysis of a prospective single tertiary care centre 14-year cohort of patients with LVO in the anterior circulation and NIHSS score ≤ 5 on admission. Outcome was analysed according to primary intended therapy.

Results: Among 185 patients (median age 67.4 years), 52.4% received primary conservative therapy (including 26.8% secondary reperfusion in case of secondary neurological deterioration), 12.4% IV thrombolysis (IVT) only and 35.1% primary endovascular therapy (EVT). 95 (51.4%) patients experienced neurological deterioration until 3 months. Primary-IVT-only and primary-EVT compared to conservative-therapy patients had better 3 months' outcome (54.5% vs. 30.8%: _adjustedOR 6.02; _adjustedp = 0.004 for mRS 0-1 and 54.7% vs. 30.8%: _adjustedOR 5.09; _adjustedp = 0.002, respectively). Also mRS shift analysis favored primary-IVT-only and primary-EVT patients (_adjustedOR 6.25; _adjustedp = 0.001 and _adjustedOR 3.14; _adjustedp = 0.003). Outcome in primary-IVT-only vs. primary-EVT patients did not differ significantly. Patients who received secondary EVT because of neurological deterioration after primary-conservative-therapy had worse 3 months' outcome than primary-EVT patients (20.8% vs. 30.8%: _adjustedOR 0.24; _adjustedp = 0.047 for mRS 0-1 and _adjustedOR 0.31; _adjustedp = 0.019 in mRS shift analysis). Survival and symptomatic intracranial haemorrhage did not differ amongst groups.

Conclusions: Our data indicate that primary IVT and/or EVT may be better than primary conservative therapy in patients with LVO in the anterior circulation and low NIHSS score. Furthermore, primary EVT was better than secondary EVT in case of neurological deterioration. There is an unmet need for RCTs to find the optimal therapy for this patient group.

Keywords: Different therapy modalities; Large vessel occlusion; Low NIHSS score; NIHSS score subitems; Outcome.

MeSH terms

Adult
Aged
Aged, 80 and over
Arterial Occlusive Diseases / drug therapy
Arterial Occlusive Diseases / therapy*
Cerebral Arterial Diseases / drug therapy
Cerebral Arterial Diseases / therapy*
Endovascular Procedures*
Female
Fibrinolytic Agents / administration & dosage
Fibrinolytic Agents / pharmacology*
Humans
Male
Middle Aged
Outcome Assessment, Health Care*
Prospective Studies
Retrospective Studies
Severity of Illness Index*
Tertiary Care Centers

Substances

Fibrinolytic Agents