J Stroke.  2023 May;25(2):272-281. 10.5853/jos.2022.03370.

Recanalization Therapies for Large Vessel Occlusion Due to Cervical Artery Dissection: A Cohort Study of the EVA-TRISP Collaboration

• Traenka C
• Lorscheider J
• Hametner C
• Baumgartner P
• Gralla J
• Magoni M
• Martinez-Majander N
• Casolla B
• Feil K
• Pascarella R
• Papanagiotou P
• Nordanstig A
• Padjen V
• Cereda CW
• Psychogios M
• Nolte CH
• Zini A
• Michel P
• Béjot Y
• Kastrup A
• Zedde M
• Kägi G
• Kellert L
• Henon H
• Curtze S
• Pezzini A
• Arnold M
• Wegener S
• Ringleb P
• Tatlisumak T
• Nederkoorn PJ
• Engelter ST
• Gensicke H
• for the EVA-TRISP Collaborators

• KMID: 2542478
• DOI: http://doi.org/10.5853/jos.2022.03370

Abstract

Background and Purpose
This study aimed to investigate the effect of endovascular treatment (EVT, with or without intravenous thrombolysis [IVT]) versus IVT alone on outcomes in patients with acute ischemic stroke (AIS) and intracranial large vessel occlusion (LVO) attributable to cervical artery dissection (CeAD).
Methods
This multinational cohort study was conducted based on prospectively collected data from the EVA-TRISP (EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients) collaboration. Consecutive patients (2015–2019) with AIS-LVO attributable to CeAD treated with EVT and/or IVT were included. Primary outcome measures were (1) favorable 3-month outcome (modified Rankin Scale score 0–2) and (2) complete recanalization (thrombolysis in cerebral infarction scale 2b/3). Odds ratios with 95% confidence intervals (OR [95% CI]) from logistic regression models were calculated (unadjusted, adjusted). Secondary analyses were performed in the patients with LVO in the anterior circulation (LVO_ant) including propensity score matching.
Results
Among 290 patients, 222 (76.6%) had EVT and 68 (23.4%) IVT alone. EVT-treated patients had more severe strokes (National Institutes of Health Stroke Scale score, median [interquartile range]: 14 [10–19] vs. 4 [2–7], P<0.001). The frequency of favorable 3-month outcome did not differ significantly between both groups (EVT: 64.0% vs. IVT: 86.8%; OR_adjusted 0.56 [0.24–1.32]). EVT was associated with higher rates of recanalization (80.5% vs. 40.7%; OR_adjusted 8.85 [4.28–18.29]) compared to IVT. All secondary analyses showed higher recanalization rates in the EVT-group, which however never translated into better functional outcome rates compared to the IVT-group.
Conclusion
We observed no signal of superiority of EVT over IVT regarding functional outcome in CeAD-patients with AIS and LVO despite higher rates of complete recanalization with EVT. Whether pathophysiological CeAD-characteristics or their younger age might explain this observation deserves further research.

Keyword

Cervical artery dissection; Stroke; Endovascular treatment; Thrombolysis

Figure

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  Figure 1. Flowchart of included and excluded patients. CeAD, cervical artery dissection; EVA-TRISP, EndoVAscular treatment and ThRombolysis in Ischemic Stroke Patients; LVO, large vessel occlusion; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale score; IVT, intravenous thrombolysis; EVT, endovascular treatment.

Reference

References

1. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009; 8:668–678.

2. Engelter ST, Lyrer P, Traenka C. Cervical and intracranial artery dissections. Ther Adv Neurol Disord. 2021; 14:17562864211037238.

3. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015; 372:11–20.

4. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015; 372:2296–2306.

5. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015; 372:1009–1018.

6. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015; 372:1019–1030.

7. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015; 372:2285–2295.

8. Jovin TG, Li C, Wu L, Wu C, Chen J, Jiang C, et al. Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion. N Engl J Med. 2022; 387:1373–1384.

9. Tao C, Nogueira RG, Zhu Y, Sun J, Han H, Yuan G, et al. Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med. 2022; 387:1361–1372.

10. Lin J, Liang Y, Lin J. Endovascular therapy versus intravenous thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis. J Neurol. 2020; 267:1585–1593.

11. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387:1723–1731.

12. Nordanstig A, Curtze S, Gensicke H, Zinkstok SM, Erdur H, Karlsson C, et al. EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry. BMJ Open. 2021; 11:e042211.

13. Scheitz JF, Gensicke H, Zinkstok SM, Curtze S, Arnold M, Hametner C, et al. Cohort profile: thrombolysis in ischemic stroke patients (TRISP): a multicentre research collaboration. BMJ Open. 2018; 8:e023265.

14. Polymeris AA, Curtze S, Erdur H, Hametner C, Heldner MR, Groot AE, et al. Intravenous thrombolysis for suspected ischemic stroke with seizure at onset. Ann Neurol. 2019; 86:770–779.

15. Gensicke H, Al Sultan AS, Strbian D, Hametner C, Zinkstok SM, Moulin S, et al. Intravenous thrombolysis and platelet count. Neurology. 2018; 90:e690–e697.

16. Traenka C, Grond-Ginsbach C, Goeggel Simonetti B, Metso TM, Debette S, Pezzini A, et al. Artery occlusion independently predicts unfavorable outcome in cervical artery dissection. Neurology. 2020; 94:e170–e180.

17. Altersberger VL, Kellert L, Al Sultan AS, Martinez-Majander N, Hametner C, Eskandari A, et al. Effect of haemoglobin levels on outcome in intravenous thrombolysis-treated stroke patients. Eur Stroke J. 2020; 5:138–147.

18. Lyden P, Brott T, Tilley B, Welch KM, Mascha EJ, Levine S, et al. Improved reliability of the NIH stroke scale using video training. Stroke. 1994; 25:2220–2226.

19. Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013; 44:2650–2663.

20. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet. 1998; 352:1245–1251.

21. Traenka C, Jung S, Gralla J, Kurmann R, Stippich C, Simonetti BG, et al. Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke – Results from the SWISS registry. Eur Stroke J. 2018; 3:47–56.

22. Compagne KCJ, Goldhoorn RB, Uyttenboogaart M, van Oostenbrugge RJ, van Zwam WH, van Doormaal PJ, et al. Acute endovascular treatment of patients with ischemic stroke from intracranial large vessel occlusion and extracranial carotid dissection. Front Neurol. 2019; 10:102.

23. Gory B, Piotin M, Haussen DC, Steglich-Arnholm H, Holtmannspötter M, Labreuche J, et al. Thrombectomy in acute stroke with tandem occlusions from dissection versus atherosclerotic cause. Stroke. 2017; 48:3145–3148.

24. Wiegers EJA, Mulder MJHL, Jansen IGH, Venema E, Compagne KCJ, Berkhemer OA, et al. Clinical and imaging determinants of collateral status in patients with acute ischemic stroke in MR CLEAN trial and registry. Stroke. 2020; 51:1493–1502.

25. Mahncke HW, Bronstone A, Merzenich MM. Brain plasticity and functional losses in the aged: scientific bases for a novel intervention. Prog Brain Res. 2006; 157:81–109.

26. Manno C, Disanto G, Bianco G, Nannoni S, Heldner M, Jung S, et al. Outcome of endovascular therapy in stroke with large vessel occlusion and mild symptoms. Neurology. 2019; 93:e1618–e1626.

27. Seners P, Perrin C, Lapergue B, Henon H, Debiais S, Sablot D, et al. Bridging therapy or IV thrombolysis in minor stroke with large vessel occlusion. Ann Neurol. 2020; 88:160–169.

28. Yeo LL, Chen VHE, Leow AS, Meyer L, Fiehler J, Tu TM, et al. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: a real-world multicenter experience. Eur J Neurol. 2021; 28:2736–2744.

29. Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, et al. European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischaemic stroke endorsed by Stroke Alliance for Europe (SAFE). Eur Stroke J. 2019; 4:6–12.

30. Marnat G, Lapergue B, Sibon I, Gariel F, Bourcier R, Kyheng M, et al. Safety and outcome of carotid dissection stenting during the treatment of tandem occlusions: a pooled analysis of TITAN and ETIS. Stroke. 2020; 51:3713–3718.