Robert W. Regenhardt, MD, PhD
International Stroke Conference 2021
March 17–19, 2021
Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate) (33, On Demand)
The session “Challenging EVT Decision Making: When, Where, and Who to Treat” (Debate) highlights some of the most difficult management decisions regarding EVT.
Dr. Sandra Narayanan built the case “Low NIHSS proximal occlusions should undergo thrombectomy.” She started by reviewing the magnitude of the question. An LVO is present in 18% of patients with NIHSS 0-4 and 39% of those with NIHSS 5-8. Furthermore, 15% of LVO stroke patients have minor symptoms. Deterioration can happen in early or delayed fashion; about 40% deteriorate early. Current guidelines suggest that treating patients with low NIHSS is reasonable. Indeed, several studies show a benefit. The Grady experience (JNIS 2017; 9:917-921) described 32 patients with NIHSS<6. Analyses of this cohort, while small, suggested a benefit of EVT. 22 were treated with medical management, of which 9 declined requiring EVT. The median time from arrival to deterioration was 5.2 hours. Subsequently, a larger study of 6 CSCs (Stroke 2018;49: 2391-2397) described 300 patients with NIHSS<6; 11.3% of those treated with medical management later declined. At 90 days, mRS 0-2 was observed in 84% of those treated with EVT, 70% of those with medical management, and 55% of those who underwent rescue EVT. Those who are allowed to deteriorate tend to have worse outcomes. The risks versus benefits should be carefully weighed up front because waiting more than 3 hours appears to impact outcomes. There is growing data that patients at risk for decline can be selected by collaterals, orthostatic challenges, perfusion imaging, and NIHSS eloquence/disability. Three randomized controlled trials are forthcoming: ENDOLOW, IN EXTREMIS, and TEMPO 2.