Efficacy and Safety of Endovascular Treatment versus Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Lin, Chao-Chang; Li, Nan; Wang, Kangyi; Zhao, Xin; Li, Baiqiang; Sun, Limei; Lin, Yingyan; Fan, Jie-Mei; Zhang, Miao; Sun, Haiyan

doi:10.1371/journal.pone.0077849

Cited by 8 publications

(6 citation statements)

References 29 publications

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“…In contrast with some previous publications 8 9 11 and the results obtained in initial trials, this systematic review and meta-analysis found that endovascular treatment, in particular thrombectomy as an add-on to intravenous rt-PA, provides beneficial functional outcomes after ischaemic stroke secondary to occlusion of anterior large vessels, without increased detrimental effects compared with medical care alone. Our results and recommendations are in accordance with other recently published systematic reviews in this specialty.…”

Section: Discussioncontrasting

confidence: 95%

“…Results for adjunctive intra-arterial mechanical thrombectomy from published randomised controlled trials are heterogeneous, and the clinical benefit of the procedure are uncertain. 8 9 10 11 We conducted a systematic review with meta-analysis to compare the efficacy and safety of endovascular treatment (in particular adjunctive intra-arterial mechanical thrombectomy) with standard medical care alone (in particular intravenous rt-PA) in adults with ischaemic stroke.…”

Section: Introductionmentioning

confidence: 99%

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Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis

Rodrigues

Neves

Caldeira

et al. 2016

BMJ

173

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Objectives To evaluate the efficacy and safety of endovascular treatment, particularly adjunctive intra-arterial mechanical thrombectomy, in patients with ischaemic stroke.Design Systematic review and meta-analysis.Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, SciELO, LILACS, and clinical trial registries from inception to December 2015. Reference lists were crosschecked.Eligibility criteria for selecting studies Randomised controlled trials in adults aged 18 or more with ischaemic stroke comparing endovascular treatment, including thrombectomy, with medical care alone, including intravenous recombinant tissue plasminogen activator (rt-PA). Trial endpoints were functional outcome (modified Rankin scale scores of ≤2) and mortality at 90 days after onset of symptoms. No language or time restrictions applied.Results 10 randomised controlled trials (n=2925) were included. In pooled analysis endovascular treatment, including thrombectomy, was associated with a higher proportion of patients experiencing good (modified Rankin scale scores ≤2) and excellent (scores ≤1) outcomes 90 days after stroke, without differences in mortality or rates for symptomatic intracranial haemorrhage, compared with patients randomised to medical care alone, including intravenous rt-PA. Heterogeneity was high among studies. The more recent studies (seven randomised controlled trials, published or presented in 2015) proved better suited to evaluate the effect of adjunctive intra-arterial mechanical thrombectomy on its index disease owing to more accurate patient selection, intravenous rt-PA being administered at a higher rate and earlier, and the use of more efficient thrombectomy devices. In most of these studies, more than 86% of the patients were treated with stent retrievers, and rates of recanalisation were higher (>58%) than previously reported. Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies. All trials were open label. Risk of bias was moderate across studies. The full results of two trials are yet to be published.Conclusions Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.Systematic review registration PROSPERO CRD42015019340.

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Section: Discussioncontrasting

confidence: 95%

Section: Introductionmentioning

confidence: 99%

Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis

Rodrigues

Neves

Caldeira

et al. 2016

BMJ

173

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“…The favourable result of the mechanical thrombectomy is strongly time-dependent ("time is brain"), with the best results being obtained when there is no evidence of extensive early ischemic brain damage; if a good re-channelling is achieved within 4.5 hours, the absolute good functional outcome index is 61% [35]. Other results from the published randomized controlled trials are heterogenous and the clinical benefits of this procedure are determined as uncertain [39][40][41][42][43].…”

Section: Discussionmentioning

confidence: 99%

Endovascular and Thrombolytic Therapy and the Functional Status of Patients after Ischemic Stroke

Jabłońska

Wronkowska

Ślusarz

et al. 2019

PNIN

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Introduction. Stroke is treated as a direct threat to life. Mechanical thrombectomy used as an independent treatment or in combination with systemic thrombolysis is currently the standard care in the treatment of ischemic stroke. Aim. Evaluation of the functional status of patients after ischemic stroke treated with thrombolysis or thrombectomy. Material and Methods. The study involved 50 patients hospitalized due to ischemic stroke. Standardized research tools were used: the Rankin scale, the Barthel scale and the Functional Index "Repty" (WFR). The study was conducted twice in one patient: on the first and ninth day after the treatment. The collected material was developed statistically. Results. Most of the respondents were men-62%. Thrombolytic treatment was used in all subjects, and thrombectomy in 26% people. Analyses showed that there were differences in the Barthel scale level Z = 4.87; p < 0.001, Rankin Z = 4.80; p < 0.001 and WFR Z = 4.83; p < 0.001. The age of the respondents was related negatively to the Barthel scale score on the 1 st day ρ =-0.51; p < 0.001 and the 9 th day ρ =-0.53; p < 0.001 and the result in the WFR scale on the 1 st day ρ =-0.54; p < 0.001 and the 9 th day ρ =-0.52; p < 0.001. Conclusions. The performance of the subjects on the 1st day of treatment was worse than on the 9th day. People who were only treated with thrombolysis had better results in fitness tests and had a lower level of disability than people treated with thrombolysis and thrombectomy.

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“…With their publications, IMS III [ 8 ], SYNTHESIS Expansion [ 9 ], and MR RESCUE [ 10 ], caused a noticeable increase in clinical skepticism regarding the utility of endovascular therapy for acute ischemic stroke. This skepticism was enhanced by subsequent meta-analyses [ 11 – 12 ] emphasizing the lack of efficacy of endovascular treatment in acute ischemic stroke patients. These trials had several notable limitations including: the selection of patients without confirmation of intervention-appropriate occlusions (large-vessel anterior-circulation occlusions), use of less effective intervention modalities including administration of intra-arterial thrombolytics alone or use of first-generation mechanical thrombectomy devices alone, less emphasis on work flow efficiencies to speed the deployment of endovascular treatment, and varied use of IV t-PA as an adjunct to endovascular intervention, especially in the SYNTHESIS Expansion[ 9 ] trial whose design was truly that of a comparative effectiveness study between endovascular treatment and IV t-PA.…”

Section: Discussionmentioning

confidence: 99%

“…Although endovascular therapy had been associated with a higher probability of recanalization [ 7 ], results of three 2013 trials (IMS III [ 8 ], SYNTHESIS Expansion [ 9 ], and MR RESCUE [ 10 ]) showed no significant benefit of endovascular treatment predominantly using first-generation mechanical thrombectomy devices compared to medical management on stroke outcomes [ 8 – 10 ]. The results and effect estimates from these trials were subsequently summarized and pooled in meta-analyses, at the time supporting the findings of no benefit for endovascular treatment compared to IV thrombolysis alone [ 11 , 12 ].…”

Section: Introductionmentioning

confidence: 98%

Endovascular Treatment with Stent-Retriever Devices for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

et al. 2016

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ImportanceAcute ischemic stroke is a leading cause of death and disability worldwide. Several recent clinical trials have shown that endovascular treatment improves clinical outcomes among patients with acute ischemic stroke.ObjectiveTo provide an overall and precise estimate of the efficacy of endovascular treatment predominantly using second-generation mechanical thrombectomy devices (stent-retriever devices) compared to medical management on clinical and functional outcomes among patients with acute ischemic stroke.Data SourcesMEDLINE, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, Web of Science, and NIH ClinicalTrials.gov were searched through November 2015.Study SelectionSearches returned 3,045 articles. After removal of duplicates, two authors independently screened titles and abstracts to assess eligibility of 2,495 potentially relevant publications. From these, 38 full-text publications were more closely assessed. Finally, 5 randomized controlled trials of endovascular treatment with predominant use of retrievable stents were selected.Data Extraction and SynthesisThree authors independently extracted information on participant and trial characteristics and clinical events using a standardized protocol. Random effects models were used to pool endovascular treatment effects across outcomes.Main Outcomes and MeasuresThe primary outcome was better functional outcome as measured on the modified Rankin Scale at 90 days of follow-up. Secondary outcomes included all-cause mortality and symptomatic intra-cerebral hemorrhage.ResultsFive trials representing 1,287 patients were included. Overall, patients randomized to endovascular therapy experienced 2.22 times greater odds of better functional outcome compared to those randomized to medical management (95% CI, 1.66 to 2.98; P < 0.0001). Endovascular therapy was not associated with mortality [OR (95% CI), 0.78 (0.54, 1.12); P = 0.1056] or symptomatic intracerebral hemorrhage [OR (95% CI), 1.19 (0.69, 2.05); P = 0.5348]. Meta-regression analysis suggested that shorter times from stroke onset to groin puncture and from stroke onset to reperfusion result in better functional outcomes in ischemic stroke patients (P = 0.0077 and P = 0.0089). There were no significant differences in the beneficial effects of endovascular treatment on functional outcomes across categories of gender, age, stroke severity, ischemic changes on computed tomography, or intravenous tissue plasminogen activator administration.Conclusions and RelevanceThis meta-analysis demonstrated superior functional outcomes in subjects receiving endovascular treatment compared to medical management. Further, this analysis showed that acute ischemic stroke patients may receive enhanced functional benefit from earlier endovascular treatment.

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Efficacy and Safety of Endovascular Treatment versus Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Cited by 8 publications

References 29 publications

Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis

Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis

Endovascular and Thrombolytic Therapy and the Functional Status of Patients after Ischemic Stroke

Endovascular Treatment with Stent-Retriever Devices for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

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