A Systematic Review and Meta-Analysis of Randomized Controlled Trials of Endovascular Thrombectomy Compared with Best Medical Treatment for Acute Ischemic Stroke

Abstract

BackgroundAcute ischemic strokes involving occlusion of large vessels usually recanalize poorly following treatment with intravenous thrombolysis. Recent studies have shown higher recanalization and higher good outcome rates with endovascular therapy compared with best medical management alone. A systematic review and meta‐analysis investigating the benefits of all randomized controlled trials of endovascular thrombectomy where at least 25% of patients were treated with a thrombectomy device for the treatment of acute ischemic stroke compared with best medical treatment have yet to be performed.AimTo perform a systematic review and a meta‐analysis evaluating the effectiveness of endovascular thrombectomy compared with best medical care for treatment of acute ischemic stroke.Summary of reviewOur search identified 437 publications, from which eight studies (totaling 2423 patients) matched the inclusion criteria. Overall, endovascular thrombectomy was associated with improved functional outcomes (modified Rankin Scale 0–2) [odds ratio 1·56 (1·32–1·85), P < 0·00001]. There was a tendency toward decreased mortality [odds ratio 0·84 (0·67–1·05), P = 0·12], and symptomatic intracerebral hemorrhage was not increased [odds ratio 1·03 (0·71–1·49), P = 0·88] compared with best medical management alone. The odds ratio for a favorable functional outcome increased to 2·23 (1·77–2·81, P < 0·00001) when newer generation thrombectomy devices were used in greater than 50% of the cases in each trial.ConclusionsThere is clear evidence for improvement in functional independence with endovascular thrombectomy compared with standard medical care, suggesting that endovascular thrombectomy should be considered the standard effective treatment alongside thombolysis in eligible patients.

A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial

“…The management committee determined that an assumption-free ordinal approach to analysis should be included as a secondary outcome (statistical analysis plan). Therefore, the analysis plan was changed such that the 3-month mRS results were dichotomised into good outcome (mRS score of 0-2) and poor outcome (mRS score of [3][4][5][6], and the groups compared using a binary logistic model. 30 The primary analysis was adjusted with baseline NIHSS and premorbid mRS as covariates.…”

“…stroke unit care 3 (a complex package of specialist multidisciplinary stroke care involving nurses, therapists and doctors) 2. aspirin for ischaemic stroke 4 3. intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) for ischaemic stroke 5 4. mechanical thrombectomy for major ischaemic stroke 6 5. emergency decompressive surgery for malignant middle cerebral artery syndrome. 7 Among these interventions, the stroke unit effect has potentially the greatest population impact as it combines both moderate effectiveness and broad applicability.…”

Development of Simulator System Using Endovascular Evaluator for Catheter Intervention Training

“…As this procedure requires trainees to manipulate the microcatheter and microwire and eventually deploy stents in intracranial vessels in addition to the placement of a guiding catheter, perfusion, and imaging, they can learn basic techniques of endovascular treatment. In addition, mechanical thrombectomy has been reported to be effective as a treatment for acute-phase cerebral infarction, [13][14][15][16] and shortening of the time until recanalization is a condition for improving the outcome. Therefore, simulation training in thrombectomy is considered to contribute to improvements in the clinical effectiveness and safety of catheter treatment.…”

An historical and contemporary review of endovascular therapy for acute ischemic stroke

“…Multiple meta-analyses, including various combinations of the three negative RCTs published in 2013 (MR RESCUE, IMS III and SYNTHESIS) with the six positive RCTs published or presented in 2015 (MR CLEAN, ESCAPE, SWIFT-PRIME, EXTEND IA, REVASCAT, THRACE) have confirmed the benefit of endovascular thrombectomy in large vessel occlusion [25][26][27][28][29][30]. The HERMES collaboration analysed individual patient level data from five of the six positive RCTs published in 2015 (MR CLEAN, ESCAPE, REVASCAT, SWIFT-PRIME and EXTEND-IA; THRACE had not yet been published) [25].…”