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  • Endovascular therapy versus best medical management in distal medium middle cerebral artery acute ischaemic stroke: a multinational multicentre propensity score-matched study

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Cerebrovascular disease
Original research
Endovascular therapy versus best medical management in distal medium middle cerebral artery acute ischaemic stroke: a multinational multicentre propensity score-matched study
  1. Hamza Adel Salim1,2,3,
  2. Vivek Yedavalli1,
  3. Basel Musmar3,
  4. Nimer Adeeb4,
  5. Kareem E l Naamani5,
  6. Nils Henninger6,
  7. Sri Hari Sundararajan7,
  8. Anna Luisa Kühn8,
  9. Jane Khalife9,
  10. Sherief Ghozy10,
  11. Luca Scarcia11,
  12. Benjamin Yong Qiang Tan12,
  13. Jeremy J Heit13,
  14. Robert W Regenhardt14,
  15. Nicole M Cancelliere15,
  16. Joshua D Bernstock16,
  17. Aymeric Rouchaud17,18,
  18. Jens Fiehler19,
  19. Muhammed Amir Essibayi20,
  20. Sunil A Sheth21,
  21. Ajit S Puri22,
  22. Xavier Barreau23,
  23. Marco Colasurdo24,
  24. Leonardo Renieri25,
  25. Christian Dyzmann26,
  26. Thomas Marotta27,
  27. Julian Spears28,29,
  28. Askan Mowla30,
  29. Pascal Jabbour31,
  30. João Pedro Filipe32,
  31. Arundhati Biswas33,
  32. Pablo Harker34,
  33. Frédéric Clarençon35,
  34. Răzvan Alexandru Radu36,
  35. James E Siegler37,
  36. Thanh N Nguyen38,
  37. Ricardo Varela39,
  38. Takahiro Ota40,
  39. Nestor Gonzalez41,
  40. Markus A Moehlenbruch42,
  41. David Altschul20,
  42. Benjamin Gory43,
  43. Vincent Costalat44,
  44. Christian Paul Stracke45,
  45. Mohammad Ali Aziz-Sultan16,
  46. Constantin Hecker46,
  47. Hamza Shaikh47,
  48. David S Liebeskind39,
  49. Amanda Baker20,
  50. Alessandro Pedicelli40,
  51. Andrea Alexandre41,
  52. Tobias D Faizy42,
  53. Illario Tancredi43,
  54. Erwah Kalsoum44,
  55. Boris Lubicz45,
  56. Aman B Patel48,
  57. Vitor Mendes Pereira49,
  58. Adrien Guenego47,
  59. Adam A Dmytriw2,50
  60. for the MAD MT Investigators
    1. 1 Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
    2. 2 Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
    3. 3 Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
    4. 4 Neurosurgery, BIDMC, Shreveport, Louisiana, USA
    5. 5 Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    6. 6 Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
    7. 7 New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
    8. 8 Mass General Brigham Inc, Boston, Massachusetts, USA
    9. 9 Cooper Hospital University Medical Center, Camden, New Jersey, USA
    10. 10 Radiology Neuroradiology Department, Mayo Clinic, Rochester, Minnesota, USA
    11. 11 Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
    12. 12 Internal Medicine, NUHS, Singapore
    13. 13 Stanford Medicine, Stanford, California, USA
    14. 14 Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston MA, Boston, Massachusetts, USA
    15. 15 Department of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
    16. 16 Brigham and Women's Hospital, Boston, Massachusetts, USA
    17. 17 Interventional Neuroradiology, Hopital Bicetre, Paris Kremlin Bicêtre, France
    18. 18 Radiology, Mayo Clinic, Rochester, Minnesota, USA
    19. 19 Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
    20. 20 Montefiore Medical Center, New York, New York, USA
    21. 21 Neurology, University of Texas - Houston, Houston, Texas, USA
    22. 22 Radiology and Neurosurgery, Univ Massachusetts, Worcester, Massachusetts, USA
    23. 23 Neuroradiology, CHU de Bordeaux, Bordeaux, France
    24. 24 Oregon Health & Science University, Portland, Oregon, USA
    25. 25 Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
    26. 26 Sana Kliniken AG, Ismaning, Bayern, Germany
    27. 27 University of Toronto, Toronto, Ontario, Canada
    28. 28 Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael’s Hospital, University of Toronto, Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael’s Hospital, University of Toronto, Pessac, France
    29. 29 Department of Surgery, Division of Neurosurgery, University of Toronto, Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
    30. 30 USC Keck School of Medicine, Los Angeles, California, USA
    31. 31 Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    32. 32 Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
    33. 33 Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA
    34. 34 University of Cincinnati, Cincinnati, Ohio, USA
    35. 35 Interventional Neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
    36. 36 Hospital Gui de Chauliac Head and Neck Neuroscience Unit, Montpellier, France
    37. 37 Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    38. 38 Neurology, Neurosurgery, Radiology, Boston University Medical Center, Boston, Massachusetts, USA
    39. 39 Neurology, University of California, Los Angeles, Los Angeles, California, USA
    40. 40 Radiological Sciences, Catholic University of Sacred Heart, “A. Gemelli” Hospital, Rome, Italy
    41. 41 Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
    42. 42 University of Münster, Munster, Germany
    43. 43 Hôpital Civil Marie Curie à Lodelinsart, Charleroi, Belgium
    44. 44 Neuroradiology, Henri Mondor Hospital, Créteil, France
    45. 45 Centre Universitair Bruxelles Hôpital Erasme, Bruxelles, Belgium
    46. 46 Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
    47. 47 Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
    48. 48 Massachusetts General Hospital, Boston, Massachusetts, USA
    49. 49 Neuroimaging Division, Toronto Western Hospital, Toronto, Ontario, Canada
    50. 50 Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
    1. Correspondence to Dr Hamza Adel Salim; Hamza.sleeem{at}gmail.com; Dr Adam A Dmytriw; admytriw{at}mgh.harvard.edu; Dr Vivek Yedavalli; vyedava1{at}jhmi.edu

    Abstract

    Background The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO.

    Methods In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0–2), excellent outcome (mRS 0–1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts.

    Results Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0–2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15).

    Conclusion Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies.

    • STROKE

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/jnnp-2024-333669

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • HAS and VY are joint first authors.

      • X @hamza_isleem, @vsyedavalli, @MAEssibayo, @PascalJabbourMD, @NguyenThanhMD, @DavidAltschulMD, @GuenegoAdrien

      • Collaborators MAD MT Investigators: Abdelaziz Amllay MD (Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA), Achala Vagal MD (Department of Neurology and Radiology, University of Cincinnati, USA), Adrien ter Schiphorst MD (Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center), Ajith J Thomas MD (Departments of Neurological Surgery), Anil Gopinathan (Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore), Anne Dusart MD (Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium), Carolina Capirossi MD (Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy), Charbel Mounayer MD (University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252), Charlotte Weyland MD (Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany), Cheng-Yang Hsieh MD (Neurology Department, Sin-Lau Hospital, Tainan, Taiwan), Christoph J Griessenauer MD (Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Austria), Christopher J Stapleton MD (Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA), Erwah Kalsoum MD (Department of Neuroradiology, Henri Mondor Hospital, Creteil, France), Flavio Bellante MD (Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium), Gaultier Marnat MD (Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France), Géraud Forestier MD (University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252), Hamza Shaikh MD (Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA), Hugo H Cuellar-Saenz MD (Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA), Iacopo Valente MD (UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy), Igor Sibon MD PhD (Neurology Department, Bordeaux University Hospital, Bordeaux, France), James D Rabinov MD (Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA), Jérôme Berge MD (Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France), Jessica Jesser MD (Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany), Juan Carlos Martinez-Gutierrez MD (Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA), Kevin Premat MD (Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast. Sorbonne University. Paris VI), Leonard L L Yeo MD PhD (Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore), Lina Chervak MD (Department of Neurology and Radiology, University of Cincinnati, USA), Lukas Meyer MD (Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany), Mahmoud Elhorany MD (Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast. Sorbonne University. Paris VI), Miguel Quintero-Consuegra MD (Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA), Mohamad Abdalkader MD (Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA), Mohammad Ali Aziz-Sultan MD (Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA), Monika Killer-Oberpfalzer MD (Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Austria), Peter T Kan MD MPH (Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA), Piers Klein MA (Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA), Priyank Khandelwal MD (Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA), Ramanathan Kadirvel PhD (Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA), Robert Fahed MD (Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada), Sergio Salazar-Marioni MD (Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA), Shogo Dofuku MD (Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan), Simona Nedelcu MD PhD (Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA), Stavropoula I Tjoumakaris MD (Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA), Suzana Saleme MD (University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252), Yasmin Aziz MD (Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH).

      • Contributors HS, VY, BM, NA, VMP, AG, AAD contributed to the conception and design of the work. HS, VY, BM, NA, KEIN, NH, SHS, ALK, JK, SG, LS, BYQT, JJH, RWR, NMC, JDB, AR, JF, SAS, MAE, ASP, CD, MC, XB, LR, JPF, PH, RAR, TM, JS, TO, AM, PJ, ABi, FC, JES, TNN, RV, ABa, DA, NG, MAM, VC, BG, CPS, MAA-S, CH, HS, DSL, AP, AA, IT, TDF, EK, BL, ABP, VMP, AG, AAD were involved in the acquisition of data, and data analysis and interpretation. HS, VY, BM, NA, KEIN, NH, SHS, ALK, JK, SG, LS, BYQT, JJH, RWR, NMC, JDB, AR, JF, SAS, MAE, ASP, CD, MC, XB, LR, JPF, PH, RAR, TM, JS, TO, AM, PJ, ABi, FC, JES, TNN, RV, ABa, DA, NG, MAM, VC, BG, CPS, MAA-S, CH, HS, DSL, AP, AA, IT, TDF, EK, BL, ABP, VMP, AG, AAD drafted the work and revised it critically for important intellectual content. All authors gave final approval of the version to be published. HS and AAD are guarantors.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.