Endovascular thrombectomy with or without intravenous alteplase for acute ischemic stroke due to large vessel occlusion: a systematic review and meta-analysis of randomized trials

Abstract

BackgroundAmong patients who had an ischaemic stroke presenting directly to a stroke centre where endovascular thrombectomy (EVT) is immediately available, there is uncertainty regarding the role of intravenous thrombolysis agents before or concurrently with EVT. To support a rapid guideline, we conducted a systematic review and meta-analysis to examine the impact of EVT alone versus EVT with intravenous alteplase in patients who had an acute ischaemic stroke due to large vessel occlusion.MethodsIn November 2021, we searched MEDLINE, Embase, PubMed, Cochrane, Web of Science, clincialtrials.gov and the ISRCTN registry for randomised controlled trials (RCTs) comparing EVT alone versus EVT with alteplase for acute ischaemic stroke. We conducted meta-analyses using fixed effects models and assessed the certainty of evidence using the GRADE approach.ResultsIn total 6 RCTs including 2334 participants were eligible. Low certainty evidence suggests that, compared with EVT and alteplase, there is possibly a small decrease in the proportion of patients independent with EVT alone (risk ratio (RR) 0.97, 95% CI 0.89 to 1.05; risk difference (RD) −1.5%; 95% CI −5.4% to 2.5%), and possibly a small increase in mortality with EVT alone (RR 1.07, 95% CI 0.88 to 1.29; RD 1.2%, 95% CI −2.0% to 4.9%) . Moderate certainty evidence suggests that there is probably a small decrease in symptomatic intracranial haemorrhage (sICH) with EVT alone (RR 0.75, 95% CI 0.52 to 1.07; RD −1.0%; 95%CI −1.8% to 0.27%).ConclusionsLow certainty evidence suggests that there is possibly a small decrease in the proportion of patients that achieve functional independence and a small increase in mortality with EVT alone. Moderate certainty evidence suggests that there is probably a small decrease in sICH with EVT alone. The accompanying guideline provides contextualised guidance based on this body of evidence.PROSPERO registration numberCRD42021249873.

Endovascular thrombectomy and intravenous alteplase in patients with acute ischemic stroke due to large vessel occlusion: A clinical practice guideline

“…The review found moderate certainty evidence of a small reduction in symptomatic intracranial hemorrhage (sICH) (RD –1.0%, 95% CI –1.8% to 0.3%) with EVT alone (Table 1). 22 …”

“…A group of researchers, with direction from the guideline steering committee and input from the panel, conducted a systematic review and meta‐analysis of RCTs exploring EVT alone versus EVT with intravenous alteplase in patients with acute ischemic stroke from a large vessel occlusion 22 . This systematic review identified eligible trials through searches of MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, clincialtrials.gov, the ISRCTN registry, and conference proceedings within the last 3 years of the International Stroke Conference, European Stroke Conference, Asia‐Pacific Stroke Meeting, and the World Stroke Congress.…”

“…A group of researchers, with direction from the guideline steering committee and input from the panel, conducted a systematic review and meta-analysis of RCTs exploring EVT alone versus EVT with intravenous alteplase in patients with acute ischemic stroke from a large vessel occlusion. 22 the fourth panel meeting, four of them were published, [14][15][16][17] and two of them were released in conference meetings. 18,19 As for the released trials, we contacted the lead investigators of each trial and confirmed the data as presented at conferences.…”

Selective S1PR1 activation improves brain infarction, neurological outcome, and cerebrovascular endothelial health following experimental ischemic injury

“…Clinically, groundbreaking treatments like thrombolysis and mechanical clot retrieval are effective [60][61][62] ; however, these interventions are associated with high mortality risk and limit options for AIS patients as delayed hospital arrival or lack of access to a stroke center remain a concern. Fingolimod demonstrated promising therapeutic potential for AIS treatment, however due to its broad S1PR pharmacological actions, cardiac safety remains a concern.…”

Intraarterial thrombolytics as an adjunct to mechanical thrombectomy in patients with basilar artery occlusion

“…Furthermore, the odds of intracranial hemorrhages (symptomatic or asymptomatic) increased when intravenous thrombolysis was administered prior to mechanical thrombectomy requiring additional consideration for increased risk when pharmacological and mechanical approaches are used in combination. 7,8 However, the existing data are almost exclusively based on acute ischemic stroke patients with anterior circulation arterial occlusion.…”