EVT with poor reperfusion linked to worse outcomes than medical management in HERMES substudy

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Mayank Goyal

Endovascular therapy (EVT) treatments that achieve poor reperfusion have been found to result in inferior clinical outcomes compared to best medical management (BMM) in large vessel occlusion (LVO) acute ischaemic stroke patients.

That is according to a substudy of the HERMES collaboration—a patient-level meta-analysis of seven randomised EVT trials: ESCAPE, EXTEND-IA, MR CLEAN, PISTE, REVASCAT, SWIFT PRIME, and THRACE.

Writing in the Journal of NeuroInterventional Surgery (JNIS), Mayank Goyal (University of Calgary, Calgary, Canada) and colleagues detail that comparisons were drawn between the outcomes in LVO stroke patients undergoing EVT plus BMM (treatment arm) who experienced poor reperfusion—defined as a modified thrombolysis in cerebral infarction [mTICI] score of 0–1 on the final, core lab-adjudicated intracranial angiography run—and in patients treated with BMM only (control arm).

Specifically, the authors relay, baseline characteristics and functional outcomes (90-day modified Rankin scale [mRS] score) were compared between the two groups, with multivariable ordinal logistic regression being utilised to adjust for pre-specified baseline variables.

From a pool of 1,764 HERMES patients, 972 were included in Goyal and colleagues’ analysis—893 in the control arm and 79 in the treatment arm with a final mTICI of 0–1.

Interestingly, the researchers note, patients in the treatment arm demonstrated worse median mRS scores at 90 days compared with those in the control arm, as per an adjusted analysis (4 [interquartile range (IQR) 3–6] vs 4 [IQR 2–5]), with an adjusted common odds ratio (OR) of 0.59.

Regarding safety-related outcomes, Goyal and colleagues relay that the rate of symptomatic intracranial haemorrhage (ICH) was not significantly different between the treatment arm (3.9%) and the control arm (3.5%; adjusted OR 0.94).

The authors’ concluding message in JNIS is that the results of this HERMES substudy “emphasise the need for additional efforts to further improve technical EVT success rates”.


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