White Matter Disease and Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

E.A. Mistry; A.M. Mistry; T. Mehta; N. Arora; A.K. Starosciak; F.D.L.R. La Rosa; J.E. Siegler; S.E. Kasner; R. Chitale; M. Fusco; M. Froehler; S. Yaghi; M. Schrag; P. Khatri

doi:10.3174/ajnr.A6478

Abstract

BACKGROUND AND PURPOSE: The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear.

MATERIALS AND METHODS: In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0–2) and moderate-to-severe (van Swieten score, 3–4) white matter disease using logistic regression: 90-day mRS 3–6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery.

RESULTS: Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58–79 years). A van Swieten score of 3–4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3–6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34–5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3–4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56–2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93–4.84; P < .001). No associations between white matter disease severity and intracerebral hemorrhage, successful recanalization, and early neurologic recovery were observed.

CONCLUSIONS: Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.

ABBREVIATIONS:

aOR: adjusted OR
EVT: endovascular treatment
ICH: intracerebral hemorrhage
VSS: van Swieten score
WMD: white matter disease

Footnotes

This work was supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke (K23NS113858; Mistry), University of Cincinnati Gardner Neuroscience Institute pilot grant, and Society of Vascular and Interventional Neurology pilot grant.
Disclosures: Eva A. Mistry—UNRELATED: Grants/Grants Pending: National Institutes of Health/National Institute of Neurological Disorders and Stroke, Vanderbilt Faculty Research Scholars Program, University of Cincinnati Gardner Neuroscience Institute, and Society of Vascular and Interventional Neurology, Comments: K23NS113858.* James E. Siegler—RELATED: Grant: National Institutes of Health, Comments: U10 NS086474 grant*; Support for Travel to Meetings for the Study or Other Purposes: American Heart Association, Comments: Junior Investigator Travel Award; UNRELATED: Payment for Lectures Including Service on Speakers Bureaus: Tufts Medical Center and Lahey Hospital & Medical Center, Boston, Massachusetts, Comments: Grand Rounds honoraria. Scott E. Kasner—UNRELATED: Consultancy: Medtronic, Bayer, Bristol-Myers Squibb; Grants/Grants Pending: W. L. Gore & Associates, Bayer, Bristol-Myers Squibb*; Royalties: Up-to-Date. Rohan Chitale—UNRELATED: Grants/Grants Pending: Cerenovus*; Payment for Lectures Including Service on Speakers Bureaus: Medtronic.* Michael Froehler—UNRELATED: Consultancy: Balt USA, Corindus Vascular Robotics, Genentech, Medtronic, Stryker, Viz.ai; Employment: Vanderbilt University Medical Center; Grants/Grants Pending: National Institutes of Health, Genentech, Stryker, Medtronic, MicroVention, Penumbra, Endophys.* Shadi Yaghi—UNRELATED: Consultancy: Medtronic.* Pooja Khatri—UNRELATED: Consultancy: Lumosa Therapeutics, Genentech, Comments: Data and Safety Monitoring Board (Lumosa), trial Principal Investigator (Genentech)*; Expert Testimony: medicolegal consultation*; Grants/Grants Pending: Cerenovus, Nervive.* *Money paid to the institution.