Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis

Abstract

BackgroundIn anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent.MethodsIn April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality.ResultsFour RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27).ConclusionsOur study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH.Protocol registration number(PROSPERO ID: CRD42021236092).

Noncontrast versus perfusion CT to select endovascular therapy in an extended time window: Systematic review/meta‐analysis

“…Prior meta‐analyses were limited by the search terms used (no restriction on the time window) and their included studies of indirect comparisons including single‐arm studies with poor comparability, high heterogeneity, and only descriptive results 6 . Therefore, we optimized the search strategy and only included two‐arm studies to avoid the aforementioned limitations.…”

“…20 Prior meta-analyses were limited by the search terms used (no restriction on the time window) and their included studies of indirect comparisons including single-arm studies with poor comparability, high heterogeneity, and only descriptive results. 6 Therefore, we opti- manifestation of ischemia within 24 hours. 22 Finally, some variables that might introduce bias, such as whether imaging assessment was completed at working hours or not, and whether patients were transferred or directly admitted, were not provided in the original studies or synthesized in the meta-analysis.…”

“…An alternative to the NCCT-based selection paradigm may reduce potential treatment delays, cost, contrast load, radiation exposure, and resource use. 5 A previous systematic review and meta-analysis 6 was limited by the search terms used and inclusion of mainly single-arm studies lacking parallel controls that are insufficient to estimate the relative treatment effect and overestimate the risk of bias. 7,8 The aim of the present systematic review and meta-analysis was to compare the efficacy and safety outcomes of EVTs with NCCT ± CTA and CTP in patients with AIS in the extended time window.…”

Assessing care dependence status and associated influencing factors among middle‐aged hemiplegic stroke patients during the post‐acute rehabilitation phase: A correlational study

“…Therefore, nursing staff should encourage patients to actively participate in physical rehabilitation exercises to restore their functional independence as soon as possible. Moreover, physical impairments also led a more significant mental distress and poor personal image among post‐stroke patients (Sequeiros et al., 2023). Other complications include impaired speech and slower ability to communicate, causing unsatisfactory communication due to poor receptive and expressive abilities of patients, which increases the frustration of post‐stroke patients.…”

CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy

“…Of note, a recent meta-analysis found that there was no difference between CTP and NCCT not only for functional independence and sICH but also for successful reperfusion and mortality. 22 However, this previous meta-analysis experienced a high degree of potential bias because single-arm studies were included. A meta-analysis from 2018 analyzing randomized trials found that patients undergoing EVT within 8 hours of symptom onset with advanced imaging achieved higher rates of successful reperfusion, which is consistent with our present findings.…”