Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis

Phan, Kevin; Dmytriw, Adam A; Lloyd, Declan; Maingard, Julian; Kok, Hong Kuan; Chandra, Ronil V.; Brooks, Mark; Thijs, Vincent; Moore, Justin M.; Chiu, Albert; Selim, Magdy; Goyal, Mayank; Pereira, Vítor Mendes; Thomas, Ajith J.; Hirsch, Joshua A; Asadi, Hamed; Wang, Nelson

doi:10.1136/neurintsurg-2018-014260

Cited by 30 publications

(28 citation statements)

References 27 publications

(4 reference statements)

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“…Finally, BT was not related to delays in groin puncture to recanalization or onset to groin puncture times, compared to BT. 20 Also, we comparatively evaluated outcomes including infarct in new territory and distal embolization complicating MT, as well as time metrics (onset to groin puncture time, groin puncture to reperfusion time), which have not been investigated in prior meta-analyses. They also offer reassurance regarding the concept of distal embolization to other vascular territories due to tPA-related thrombi dissolution, preventing successful MT.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9][10] Taking into account (1) the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT) using tissue plasminogen activator (tPA), 11 (2) the substantial treatment effect of MT compared to standard therapy, 12 (3) the consistent improvement in 3-month functional outcomes of both tPA-eligible and tPA-ineligible LVO patients treated with MT, 13 and (4) the potential of IVT pretreatment to delay MT initiation and increase hemorrhagic complications of MT, 14 the utility of IVT pretreatment in LVO patients undergoing MT has been challenged. 15,16 Given that no RCT to date has evaluated the safety and efficacy of bridging therapy (BT; IVT administration prior to MT) compared to direct MT (dMT) and that existing metaanalyses of available observational studies have provided fragmentary and conflicting results to date, [17][18][19][20][21] we performed a comprehensive systematic review and meta-analysis of observational studies and post hoc RCT analyses to investigate the comparative safety and efficacy of BT and dMT in AIS patients with LVO.…”

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confidence: 99%

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Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Katsanos

Malhotra

Goyal

et al. 2019

Annals of Neurology

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Objective: The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT; IVT followed by MT) compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusion (LVO). Methods: We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post hoc analyses from randomized controlled clinical trials that provided data on the outcomes of AIS patients with LVO stratified by IVT treatment status prior to MT. Results: We identified 38 eligible observational studies (11,798 LVO patients, mean age = 68 years, 56% treated with BT). In unadjusted analyses, BT was associated with a higher likelihood of 3-month functional independence (odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.32-1.76), 3-month functional improvement (common OR [cOR] for 1-point decrease in modified Rankin Scale score = 1.52, 95% CI = 1.18-1.97), early neurological improvement (OR = 1.21, 95% CI = 1.83-1.76), successful recanalization (OR = 1.22, 95% CI = 1.02-1.46), and successful recanalization with ≤2 device passes (OR = 2.28, 95% CI = 1.43-3.64) compared to dMT. BT was also related to a lower likelihood of 3-month mortality (OR = 0.64, 95% CI = 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of 3-month functional independence (adjusted OR = 1.55, 95% CI = 1.26-1.91) and lower odds of 3-month mortality (adjusted OR = 0.80, 95% CI = 0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR = 1.24, 95% CI = 0.89-1.74) or symptomatic intracranial hemorrhage (adjusted OR = 0.87, 95% CI = 0.61-1.25).Interpretation: BT appears to be associated with improved functional independence without evidence for safety concerns, compared to dMT, for AIS patients with LVO.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Katsanos

Malhotra

Goyal

et al. 2019

Annals of Neurology

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“…Maingard et al reported that patients who received bridging therapy had a higher rate of reperfusion and functional independence (mRS 0-2 at 90 days) (21). Contrastingly, a network meta-analysis of 12 studies with a total of 3,161 patients showed that there was no significant difference in good functional outcome at 90 days between direct thrombectomy and bridging therapy (22). However, a comparison of the occurrence of PH between these two treatment options was rarely mentioned.…”

Section: Discussionmentioning

confidence: 99%

“…Patients had a median age of 71.5 years (IQR, 61.3-79 years), and 15 (28.8%) were females. The median baseline NIHSS score was 20 (IQR, [16][17][18][19][20][21][22][23]. SMCV− was found in 21 patients (40.4%) (univariate comparisons between SMCV− and SMCV+ are shown in Table S1).…”

Section: Patient Characteristicsmentioning

confidence: 99%

Absent filling of the superficial middle cerebral vein is associated with reperfusion but not parenchymal hematoma in stroke patients undergoing thrombectomy: an observational study

Zhang¹,

Zhang²,

Jin³

et al. 2020

Ann Transl Med

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Background: Parenchymal hematoma (PH) is the most feared complication of reperfusion therapy after stroke. The opacification of the superficial middle cerebral vein (SMCV) on computed tomography perfusion (CTP) has been associated with poor functional outcomes after stroke, while its association with PH has not been verified for acute stroke patients undergoing thrombectomy.Methods: Consecutive patients with acute anterior large artery occlusion (LAO) who received thrombectomy were retrospectively enrolled between May 2018 and May 2019. Absent filing of the SMCV (SMCV−) on CTP-derived CT angiography was defined as no contrast filling of the SMCV across the whole venous phase in the ischemic hemisphere, while SMCV+ was defined as the presence of contrast filling of the SMCV at any time point of the venous phase.Results: A total of 52 patients were enrolled in the study, and 15 patients (28.8%) developed a PH within 48 hours after thrombectomy. SMCV− was not associated with PH in both the univariate and multivariate logistic regression analyses (all P>0.05), but was an independent risk factor for reperfusion [modified thrombolysis in cerebral infarction score of 2b-3; odds ratio (OR) =0.172, 95% confidence interval (CI): 0.031-0.960, P=0.045]. Reperfusion was associated with a reduced risk of PH (OR =0.110, 95% CI: 0.013-0.913, P=0.041). However, in a subgroup analysis of patients who had reperfusion, the SMCV− group had a higher rate of PH than the SMCV+ group (40.0% vs. 13.8%, P=0.049). Conclusions:In patients who received thrombectomy, SMCV− did not predict PH, but was a risk factor for reperfusion. Although reperfusion was a protective factor for PH, the SMCV− group was still at a higher risk of PH compared with the SMCV+ group when reperfusion was successfully achieved.

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“…Acute ischemic stroke (AIS) is one of the most common strokes that occur in the clinical practice. It is mainly caused by cerebral blood flow disorders, which further leads to ischemic brain necrosis or encephalomalacia[1,2]. For these patients, early therapeutic strategy, especially the widely used revascularization and intravesical therapy, should be used to reduce disability and death rates.…”

Section: Introductionmentioning

confidence: 99%

Relationship between homocysteine level and prognosis of elderly patients with acute ischemic stroke treated by thrombolysis with recombinant tissue plasminogen activator

Li¹,

Zhou²,

Wu³

2019

WJCC

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BACKGROUNDAcute ischemic stroke (AIS) is mainly caused by cerebral blood flow disorders, which further leads to ischemic brain necrosis or encephalomalacia. The role of homocysteine (Hcy), an independent risk factor for cardiovascular disease, in the development of atherosclerosis is gradually revealed. However, studies are still rare and little is known about the relationship of Hcy level with the prognosis.AIMTo explore the relationship between Hcy level and prognosis in elderly patients with AIS after thrombolytic therapy with recombinant tissue plasminogen activator (rtPA).METHODSA total of 120 patients with acute ischemic stroke who were admitted to Jingzhou Central Hospital and underwent recombinant tissue plasminogen activator treatment were randomly selected from January 2017 to December 2018. They were divided into two groups according to the level of Hcy, with 60 patients in each group. Patients with Hcy ≥ 18.54 umol/L were included into a high-level group and those with Hcy < 18.54 umol/L were included into a low-level group. The outcomes were analyzed in the two groups after the treatment.RESULTSThe National institute of Health Stroke Scale (NIHSS) scores were significantly higher in the high-level group than in the low-level group before and 1 h after the treatment (P < 0.05). There was no significant difference in NIHSS scores between the two groups at 12 and 24 h after the treatment (P > 0.05). The Modified Rankin scale (MRS) scores were significantly higher in the high-level group than in the low-level group before and 1 h after the treatment (P < 0.05). There was no significant difference in MRS scores between the two groups at 12 and 24 h after the treatment (P > 0.05). NIHSS and MRS scores were positively correlated with the prognosis after thrombolytic therapy (P < 0.05).CONCLUSIONThe level of Hcy is closely related to the prognosis of elderly patients with acute ischemic stroke, and after rtPA treatment, the prognosis of elderly patients is improved significantly.

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Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis

Cited by 30 publications

References 27 publications

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Absent filling of the superficial middle cerebral vein is associated with reperfusion but not parenchymal hematoma in stroke patients undergoing thrombectomy: an observational study

Relationship between homocysteine level and prognosis of elderly patients with acute ischemic stroke treated by thrombolysis with recombinant tissue plasminogen activator

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