Intra-arterial mechanical thrombectomy stent retrievers and aspiration devices in the treatment of acute ischaemic stroke: A systematic review and meta-analysis with trial sequential analysis

Abstract

Purpose: Intra-arterial mechanical thrombectomy combined with appropriate patient selection (image-based selection of acute ischaemic stroke patients with large artery occlusion) yields improved clinical outcomes. We conducted a systematic review and meta-analysis, with trial sequential analysis to understand the benefits, risks and impact of new trials reporting in 2016 on the magnitude/certainty of the estimates for clinical effectiveness and safety of mechanical thrombectomy. Method: Random effects' models were conducted of randomised clinical trials comparing mechanical thrombectomy (stent retriever or aspiration devices) with/without adjuvant intravenous thrombolysis with intravenous thrombolysis and other forms of best medical/supportive care in the treatment of acute ischaemic stroke. Study inclusion and risk of bias were assessed independently by two reviewers. Functional independence (modified Rankin Scale 0-2) and mortality at 90 days, including symptomatic intracranial haemorrhage rate were extracted. Trial sequential analysis established the strength of the evidence derived from the meta-analyses. Findings: Eight trials of mechanical thrombectomy with a total sample size of 1841 (916 patients treated with mechanical thrombectomy and 925 treated without mechanical thrombectomy) fulfilled review inclusion criteria. The three most recent trials more precisely defined the effectiveness of mechanical thrombectomy (modified Rankin Scale 0 to 2; OR ¼ 2.07, 95% CI ¼ 1.70 to 2.51 based on data from eight trials versus OR ¼ 2.39, 95% CI ¼ 1.88 to 3.04 based on data from five trials). Meta-analyses showed no effect on mortality (OR ¼ 0.81, 95% CI ¼ 0.61 to 1.07) or symptomatic intracranial haemorrhage (OR ¼ 1.22, 95% CI ¼ 0.80 to 1.85) as found in analysis of first five trials. Trial sequential analysis indicated that the information size requirement was fulfilled to conclude the evidence for mechanical thrombectomy is robust. Discussion: The impact of three recent trials on effectiveness and safety of mechanical thrombectomy was a more precise pooled effect size for functional independence. Trial sequential analysis demonstrated sufficient evidence for effectiveness and safety of mechanical thrombectomy. Conclusion: No further trials of mechanical thrombectomy versus no mechanical thrombectomy are indicated to establish clinical effectiveness. Uncertainty remains as to whether mechanical thrombectomy reduces mortality or increases risk of symptomatic intracranial haemorrhage.

The Minimal Clinically Important Difference for Achievement of Substantial Reperfusion With Endovascular Thrombectomy Devices in Acute Ischemic Stroke Treatment

“…To identify a large pool of potential survey recipients who were neuro-interventionalists or noninterventional vascular neurologists with expertise in modern endovascular thrombectomy care, we examined the study center listings in 15 recent large, multicenter endovascular thrombectomy studies, including the eight randomized superiority-design trials of endovascular mechanical thrombectomy vs. medical therapy alone identified in a recent systematic review (MR CLEAN, ESCAPE, SWIFT-PRIME, EXTEND-IA, REVASCAT, THRACE, PISTE, THERAPY) ( 17 ), one superiority design trial comparing contact aspiration vs. stent retriever (ASTER) as well as the four controlled noninferiority design trials comparing different endovascular mechanical thrombectomy techniques identified in another recent systematic review (SWIFT, TREVO 2, Penumbra-3D, ARISE II) ( 14 ), and three recent large multicenter observational studies in the United States (TRACK, STRATIS, NASA). For each study, we identified the 10 highest enrolling centers and, for those centers, abstracted the names of (1) the site principal investigator, (2) the site co-investigator whose last name was earliest in alphabetic order, and (3) the site co-investigator whose last name was last in alphabetic order.…”

In vitro testing of a funnel-shaped tip catheter model to decrease clot migration during mechanical thrombectomy

“…To improve recanalization rates and to overcome the well-known limitations of endovascular MT, different alternative techniques for mechanical thrombectomy have been proposed and tested 6,10 . However, to the best of our knowledge no studies have investigated differently shaped tips of the DAC.…”

Estimation of stroke outcomes based on time to thrombolysis and thrombectomy

“…Of patients with acute ischaemic stroke, approximately 40% have a large vessel occlusion (LVO) [5] . More recently mechanical thrombectomy (MT) has shown substantially improved clinical outcomes for patients with LVO [6] . MT is effective up to 6 hours or more after stroke onset, depending on patient selection, but also demonstrates steeply reducing benefit with increasing time from stroke onset [7,8] .…”