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      Endovascular Treatment Versus Best Medical Management in Acute Basilar Artery Occlusion Strokes: Results From the ATTENTION Multicenter Registry

      1 , 2 , 1 , 1 , 1 , 1 , 1 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 1 , on behalf of the ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) Trial Investigators
      Circulation
      Ovid Technologies (Wolters Kluwer Health)

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          Abstract

          Background:

          The authors compare the effectiveness and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes attributable to acute basilar artery occlusion (BAO).

          Methods:

          The present analysis was based on the ongoing, prospective, multicenter ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial registry in China. Our analytic sample comprised 2134 patients recruited at 48 sites between 2017 and 2021 and included 462 patients who received BMM and 1672 patients who received EVT. We performed an inversed probability of treatment weighting analysis. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favorable functional outcome (modified Rankin Scale score, 0–3) at 90 days. We also performed a sensitivity analysis with the propensity score matching–based and the instrumental variable–based analysis.

          Results:

          In our primary analysis using the inversed probability of treatment weighting–based analysis, there was a significantly higher rate of favorable outcome at 90 days among EVT patients compared with BMM-treated patients (adjusted relative risk, 1.42 [95% CI, 1.19–1.65]; absolute risk difference, 11.8% [95% CI, 6.9–16.7]). The mortality was significantly lower (adjusted relative risk, 0.78 [95% CI, 0.69–0.88]; absolute risk difference, −10.3% [95% CI, −15.8 to −4.9]) in patients undergoing EVT. Results were generally consistent across the secondary end points. Similar associations were seen in the propensity score matching–based and instrumental variable–based analysis.

          Conclusions:

          In this real-world study, EVT was associated with significantly better functional outcomes and survival at 90 days. Well-designed randomized studies comparing EVT with BMM in the acute BAO are needed.

          Registration:

          URL: www.chictr.org.cn ; Unique identifier: ChiCTR2000041117.

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          Most cited references43

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          An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies

          The propensity score is the probability of treatment assignment conditional on observed baseline characteristics. The propensity score allows one to design and analyze an observational (nonrandomized) study so that it mimics some of the particular characteristics of a randomized controlled trial. In particular, the propensity score is a balancing score: conditional on the propensity score, the distribution of observed baseline covariates will be similar between treated and untreated subjects. I describe 4 different propensity score methods: matching on the propensity score, stratification on the propensity score, inverse probability of treatment weighting using the propensity score, and covariate adjustment using the propensity score. I describe balance diagnostics for examining whether the propensity score model has been adequately specified. Furthermore, I discuss differences between regression-based methods and propensity score-based methods for the analysis of observational data. I describe different causal average treatment effects and their relationship with propensity score analyses.
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            Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

            Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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              Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.

              In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included.
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                Author and article information

                Contributors
                Journal
                Circulation
                Circulation
                Ovid Technologies (Wolters Kluwer Health)
                0009-7322
                1524-4539
                July 05 2022
                July 05 2022
                : 146
                : 1
                : 6-17
                Affiliations
                [1 ]Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei Anhui, 230001, China (C.T., Y.Y., J.L., R.L., P.X., J.Sun, W.H.).
                [2 ]Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis (A.I.Q.).
                [3 ]Department of Neurology, Maoming People’s Hospital, Guangdong, China (G.L.).
                [4 ]Department of Neurosurgery, Zhoukou Central Hospital, China (X.Y.).
                [5 ]Department of Neurology, Nanjing First Hospital, China (H.S.).
                [6 ]Department of Neurovascular Intervention, Cangzhou Central Hospital, China (Yongchang Liu).
                [7 ]Department of Neurology, Suzhou Municipal Hospital, China (Z.M.).
                [8 ]Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China (J.Z.).
                [9 ]Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, China (G.X.).
                [10 ]Department of Neurology, Qingdao Central Hospital, Qingdao University, China (B.X.).
                [11 ]Department of Neurology, Taizhou First People’s Hospital, China (C.X.).
                [12 ]Department of Neurology, Jingzhou Central Hospital, China (J.Su).
                [13 ]Department of Neurology, Hunan Provincial People’s Hospital, Changsha, China (W.Z.).
                [14 ]Department of Neurology, Hospital 302 Attached to Guizhou Aviation Group, Guizhou, China (S.H.).
                [15 ]Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China (W.Y.).
                [16 ]Department of Neurology and Stroke Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (H.C.).
                [17 ]Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou, China (W.Li).
                [18 ]Department of Neurology, Fujian Provincial Hospital, Fuzhou, China (Y.Li).
                [19 ]Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, China (D.L.).
                [20 ]Department of Neurology, The First Affiliated Hospital of Anhui University of Science and Technology, Huainan, China (C.Y.).
                [21 ]Department of Emergency, Xiangtan Central Hospital, China (G.Y.).
                [22 ]Department of Neurology, Liangxiang Hospital, Fangshan District, Beijing, China (C.W.).
                [23 ]Department of Neurology, Karamay Central Hospital, China (W.Liang).
                [24 ]Department of Neurology, The First Affiliated Hospital of Kunming Medical University, China (Chun Chen).
                [25 ]Department of Neurology, Anqing Hospital Affiliated to Anhui Medical University, China (X.S.).
                [26 ]Department of Neurology, General Hospital of Wan-bei Coal and Electricity Group, The Third Hospital Affiliated of Bengbu Medical College, Suzhou, China (J.W.).
                [27 ]Department of Neurology, Lishui Municipal Central Hospital, China (X.C.).
                [28 ]Department of Neurology, Central People’s Hospital of Zhanjiang, Guangdong, China (C.S.).
                [29 ]Department of Neurology, Heze Municipal Hospital, China (K.L.).
                [30 ]Department of Neurology, The First Affiliated Hospital of Nanchang University, China (P.F.).
                [31 ]Department of Neurology, Nanyang Second General Hospital, China (M.W.).
                [32 ]Department of Neurosurgical Intervention, Dalian Municipal Central Hospital, China (Z.C.).
                [33 ]Department of Neurology, The Second People’s Hospital of Nanning, China (T.L.).
                [34 ]Department of Neurology, The First Affiliated Hospital of Medicine Macau University of Technology, Zhuhai, China (G.C.).
                [35 ]Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, China (Y.S.).
                [36 ]Department of Neurology, ORDOS Central Hospital, ORDOS, China (Y.Wu).
                [37 ]Department of Neurology, Chengdu Fifth People’s Hospital, China (Y.Wang).
                [38 ]Department of Neurosurgery, The Second Affiliated Hospital of Bengbu Medical College, China (H.Z.).
                [39 ]Department of Neurosurgery, Tongling People’s Hospital, China (J.C.).
                [40 ]Department of Neurology, Taizhou Municipal Hospital, China (X.X.).
                [41 ]Department of Neurology, Fuyang People’s Hospital, China (Y.Wang.).
                [42 ]Department of Neurology, Taihe County People’s Hospital, China (W.G.).
                [43 ]Department of Neurology, Huangshan People’s Hospital, China (C.N.).
                [44 ]Department of Neurology, The Second People’s Hospital of Anhui Province, Hefei, China (Changchun Chen).
                [45 ]Department of Neurology, Jingjiang People’s Hospital, the Seventh Affiliated Hospital of Yangzhou University, China (Yan Liu).
                [46 ]Department of Neurosurgery, Jingzhou First People’s Hospital, China (J.M.).
                [47 ]Department of Neurology, Affiliated Hospital of Jinggangshan University, Ji’an, China (Y.Z.).
                [48 ]Department of Neurology, Changsha First Hospital, China (Y.Liang).
                [49 ]Department of Neurology, Taiyuan Central Hospital, China (C.W.).
                [50 ]Lehigh Valley Health Network, Allentown, PA (B.W.B.).
                [51 ]UPMC Stroke Institute, Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (R.G.N.).
                Article
                10.1161/CIRCULATIONAHA.121.058544
                35656816
                6d375df1-c851-4c04-8f64-6df9c0026228
                © 2022
                History

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