Mechanical thrombectomy alone versus with thrombolysis for ischemic stroke: A meta-analysis of randomized trials

Abstract

Introduction Mechanical thrombectomy (MT) is the standard of care in eligible patients presenting with acute ischemic stroke (AIS). The question of whether intravenous thrombolysis (IVT) improves outcomes in conjunction with MT remains unanswered. We performed a systematic review and meta-analysis of published randomized controlled trials (RCT) to explore outcomes of MT with and without IVT. Methods Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Embase, Web of science, and Scopus. Outcomes of interest included 90-day modified Rankin Scale (mRS) 0–2, thrombolysis in cerebral infarction (TICI) score 2b-3, symptomatic intracranial hemorrhage (sICH), distal embolization, and mortality. We calculated pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI). Results Six RCTs with 2334 patients compared outcomes of patients treated with MT alone and MT with IVT. Both treatments resulted in comparable rates of mRS 0–2 (RR = 0.96, 95% CI = 0.88–1.04; p-value = 0.282), sICH (RR = 0.80, 95% CI = 0.55–1.17; p-value = 0.253), mortality at 90-days (RR = 1.06, 95% CI = 0.88–1.28; p-value = 0.529), and distal embolization (RR = 1.10, 95% CI = 0.79–1.52; p-value = 0.572). MT alone was associated with a lower rate of TICI 2b-3 compared to MT with IVT (RR = 0.96, 95% CI = 0.93–0.99; p-value = 0.006). Conclusions In this meta-analysis of six RCTs, MT alone was comparable to MT plus IVT for mRS 0–2, sICH, mortality, and distal embolization; however, MT alone resulted in lower rates of TICI 2b-3. Further trials are needed to determine which patient populations benefit from MT plus IVT and to increase the power of future meta-analyses.

The pivotal role of timing of intravenous thrombolysis bridging treatment prior to endovascular thrombectomy

“…This finding is in agreement with the previously published meta-analyses showing the overall positive effect of bridging-IVT on successful recanalization rates. 2,4 By contrast, in the 2–4 h OTD patients, IVT was not associated with higher rates of target recanalization and was associated with higher rates of HT and poor outcomes. We further demonstrated that the beneficial effect of thrombolysis is higher among patients with OTD below 90 min, and lowest among patients with OTD above 180 min.…”

“…1 The role of intravenous thrombolysis (IVT) as a bridging treatment prior to EVT is still debatable. Although current guidelines advocate for IVT treatment in all eligible LVO cases, 1 studies examining bridging treatment, including six randomized control trials and several meta-analyses, [2][3][4] have demonstrated inconclusive results. Finding subpopulations that may benefit or conversely be harmed by the IVT + EVT approach may allow better patient selection that could potentially lead to improved outcomes.…”

2023 Neurocritical Care Updates in Cerebrovascular Disease

“…A recently published meta-analysis of all 4 large core trials demonstrated that while symptomatic ICH was greater with EVT, clinical/outcome benefit persisted. 2…”

“…Thrombectomy trials for large ischemic cores including an extended time window have shown promise. 1–3 The debate on hemodynamic management after endovascular therapy (EVT) for acute ischemic stroke persists, increasingly suggesting that generalized blood pressure (BP) reduction may be harmful. Further investigations explore a potential role for precision medicine.…”

Endovascular thrombectomy for acute ischemic stroke with a large infarct area: an updated systematic review and meta-analysis of randomized controlled trials

“…Over the last decade, studies have showcased a clear benefit of endovascular thrombectomy (EVT) over medical therapy (MEDT) alone in managing acute ischemic stroke (AIS) due to large vessel occlusion (LVO) (1). Therefore, current guidelines advocate for EVT in individuals presenting with Alberta Stroke Program Early CT Score (ASPECTS) ≥6 (range: 0-10, inverse relation with the infarction size) (2,3).…”