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Endovascular stroke treatment’s impact on malignant type of edema (ESTIMATE)

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A Correction to this article was published on 06 May 2020

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Abstract

Background and purpose

In patients with acute ischemic stroke and large vessel occlusion, the prognosis has improved tremendously since the implementation of endovascular thrombectomy (EVT). The effect of EVT on the incidence of malignant middle cerebral artery infarctions (MMI) has not been studied before.

Methods

ESTIMATE, a multicenter retrospective study, evaluates data of ischemic stroke patients with occlusion in the anterior circulation in the years of 2007–2015 comparing three treatment options (no therapy; IV-TPA; IV-TPA plus EVT or EVT only). Primary endpoint of the study was the incidence of MMI on follow-up imaging and mortality rates. Secondary endpoints were functional outcome, further clinical and imaging data. Logistic and Cox-regression models with a propensity score weighting approach were applied to evaluate differences between treatment groups.

Results

In 2161 patients over 9 years, EVT reduced the MMI rates significantly: patients without acute stroke treatment had increased odds for MMI of 1.57 [95% confidence interval (CI) 1.49–1.65]. In contrast, after treatment with IV-TPA, only we observed an OR of 0.88 (95% CI 0.83–0.94, p < 0.001), and after EVT an OR of 0.80 (95% CI 0.76–0.85, p < 0.001). This was more pronounced in larger pretreatment infarctions (ASPECTS < 5, p < 0.01). IV-TPA also lowers the MMI rates but not to the same extent. EVT-treated patients had increased survival rates (p < 0.05) and the best functional outcome at discharge.

Conclusions

The findings of this study illustrate that occurrence of MMI and mortality rates was significantly reduced in patients treated with EVT.

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Change history

  • 06 May 2020

    The original keywords were not sufficiently precise in describing the article content. Therefore, the key words were amended to include hemicraniectomy and malignant edema.

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Author information

Author notes

  1. Hannah Fuhrer, Silvia Schönenberger, Peter Ringleb, and Hermann Neugebauer contributed equally to first/senior authorship.

Authors and Affiliations

  1. Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany

    Hannah Fuhrer & Wolf-Dirk Niesen

  2. Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany

    Silvia Schönenberger & Peter Ringleb

  3. Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany

    Svenja Seide & Meinhard Kieser

  4. Department of Neurology, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany

    Johannes Meyne

  5. Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany

    Stefan T. Gerner & Hagen B. Huttner

  6. Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany

    Christoph Vollmuth & Hermann Neugebauer

  7. Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany

    Christopher Beck & Stephan Meckel

  8. Department of Nuclear medicine, University Hospital Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany

    Christopher Beck

  9. Department of Neuroradiology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany

    Michael Schocke

  10. Department of Neuroradiology, University Hospital Kiel, Arnold-Heller-Straße 9, 24105, Kiel, Germany

    Fritz Wodarg

  11. Department of Neuroradiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany

    Markus A. Möhlenbruch

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  1. Hannah Fuhrer
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For the IGNITE-study group

Corresponding author

Correspondence to Hannah Fuhrer.

Ethics declarations

Ethical approval

This study was carried out in accordance with the declaration of Helsinki and the recommendations and approval of the protocol of the leading ethics committee, Germany (University of Ulm, EK64/16, 10.03.2016), and the local committees of the other participating centers. As ESTIMATE is a retrospective study, the boards waived the need for patient consent.

Conflicts of interest

Dr. Beck has nothing to disclose. Dr. Fuhrer has nothing to disclose. Dr. Gerner has nothing to disclose. Dr. Huttner has nothing to disclose. Dr. Kieser has nothing to disclose. Dr. Meckel reports personal fees from Acandis GmbH, other from Covidien/Medtronic; Microvention; Stryker, grants from Bracco S.p.A., outside the submitted work; Dr. Meyne reports non-financial support from Boehringer Ingelheim, non-financial support from Daiichi Sankyo, outside the submitted work; Dr. Möhlenbruch reports personal fees from Board Membership, grants and personal fees from Consultancy, grants from Grant, grants and personal fees from Payment for lectures including Ðervice on speakers bureaus, outside the submitted work; Dr. Neugebauer has nothing to disclose. Dr. Niesen has nothing to disclose. Dr. Ringleb reports personal fees from Boehringer Ingelheim, personal fees from Bayer, personal fees from Pfizer, personal fees from BMS, outside the submitted work; Dr. Schocke has nothing to disclose. Dr. Schönenberger has nothing to disclose. Svenja Seide has nothing to disclose. Christoph Vollmuth has nothing to disclose. Dr. Wodarg has nothing to disclose.

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Fuhrer, H., Schönenberger, S., Niesen, WD. et al. Endovascular stroke treatment’s impact on malignant type of edema (ESTIMATE). J Neurol 266, 223–231 (2019). https://doi.org/10.1007/s00415-018-9127-x

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  • DOI: https://doi.org/10.1007/s00415-018-9127-x

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