Muhammad Zeeshan Memon, MD
Li S, Zi W, Chen J, Zhang S, Bai Y, Guo Y, et al. Feasibility of Thrombectomy in Treating Acute Ischemic Stroke Because of Cervical Artery Dissection. Stroke. 2018
Acute ischemic stroke associated with cervical artery dissection is traditionally treated with anticoagulants or antiplatelet agents. However, hyperacute stroke patients with large artery occlusion because of cervical artery dissection may not have good outcomes even if treated with intravenous thrombolysis. The feasibility of thrombectomy in treating acute ischemic stroke because of cervical artery dissection has not been probed well.
In this multicenter study from China, the investigators compared outcomes of 48 patients treated with endovascular treatment matched by propensity score to 48 historical control managed with medical treatment only. Patients were included in the study if they had a large artery occlusion (ICA,M1) which was attributed to cervical artery dissection. The diagnosis of cervical artery dissection was based on typical radiologic characteristics, on magnetic resonance angiography, CT angiography, or digital subtraction angiography. Only patients with thrombectomy performed within 6 hours with stent retrievers were included in the interventional arm. For single artery occlusion, a stent retriever was usually used first; for tandem artery occlusions, priority to treat the proximal or the distal occlusion was decided by the operator depending on the lesion profiles. The authors reported that the proportion of favorable outcome (modified Rankin Scale score of 0–2) was higher in patients with thrombectomy than in those without (66.7% versus 39.6%; P=0.008). There were no significance differences about the incidence of symptomatic intracranial hemorrhage (8.3% versus 4.2%; P=0.677) and the 90-day mortality (10.4% versus 6.3%; P=0.714) between matched patients with and without thrombectomy.
Previous studies comparing medical treatment with mechanical thrombectomy have shown mixed results. From the SWISS Registry which compared the endovascular therapy versus intravenous thrombolysis in 62 cervical artery dissection patients, there was no superiority of endovascular treatment over intravenous thrombolysis. The current study also observed a higher ratio of SICH (8.3%) compared with previous studies, which the authors attribute to longer mean time onset to puncture and puncture to recanalization.
It is important to point out several limitations of this study, including retrospective design and multiple participating centers without uniform protocols, which may have increased the heterogeneity of the study. Lastly, thrombectomy patients were compared with historical controls several years earlier, and only stent retrievers were used for thrombectomy, which can lead to selection and treatment bias in this cohort.
Nevertheless, the results are promising, and feasibility and efficacy of thrombectomy in stroke patients because of cervical artery dissection should be investigated further in a large prospective study.
The results of this study indicated that,
(1) Although thrombectomy in treating acute ischemic stroke due to cervical artery dissection is generally efficacious, but may introduce higher risk of intracranial hemorrhage than in treating stroke of other etiologies.
(2) The longer time from puncture to recanalization indicated the more technical challenges during thrombectomy. specific devices should be developed for stroke patients with dissection.
(3) a randomized clinical trial is warranted to confirm the efficacy and safety of thrombectomy in treating acute ischemic stroke due to cervical artery dissection.