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

Abstract

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.

Selection criteria for endovascular therapy for acute ischaemic stroke: Are patients missing out?

“…Intervention with ECR was favoured in patients aged greater than 80 years, a baseline NIHSS <10 and >20, those with M2 segment occlusion, pre‐treatment CT ASPECTS 0–7, patients not receiving intravenous (IV) tPA, delayed randomisation more than 300 minutes after onset and presence of tandem lesions. Intervention was significantly favoured in those aged greater than 80 years, patients not receiving IV tPA and delayed randomisation . Treating patients with low NIHSS is controversial.…”

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].…”

“…The largest meta-analysis to date included the above eight trials but also preliminary data from THERAPY and THRACE, and showed similar benefit with risk ratio for good functional outcome (mRS 0-2) at 90 days reported as 1.37; 95% CI 1.14-1.64 [27]. A subgroup of the seven trials published or presented in 2015, more reflective of current practice with improved patient selection and use of retrievable stents, yielded a risk ratio of 1.56 (95% CI 1.38-1.75) for a good functional outcome (mRS 0-2) at 90 days.…”

Initial experience with vascular plug devices for mechanical thrombectomy in symptomatic neonates and infants

“…In cases of acute threat to life or limb, thrombolysis or mechanical thrombectomy (MT) may be considered, particularly if expeditious resolution of thrombus burden is necessary . MT now plays an integral role in the acute response to embolic cerebrovascular accident and also in certain cases of acute myocardial infarction . MT appears to be infrequently used in pediatrics, even in situations of unsuccessful thrombolysis or when a patient is at high risk of bleeding with thrombolysis, in part because of an absence of size‐appropriate, purpose‐built thrombectomy devices .…”