Improved clinical outcome 3 months after endovascular treatment, including thrombectomy, in patients with acute ischemic stroke: a meta-analysis

Abstract

Background and purpose: Intravenous thrombolysis with tissue plasminogen activator is standard treatment in acute stroke today. The benefit of endovascular treatment has been questioned. Recently, studies evaluating endovascular treatment and intravenous thrombolysis compared with intravenous thrombolysis alone, have reported improved outcome for the intervention group. The aim of this study was to perform a meta-analysis of randomized controlled trials comparing endovascular treatment in addition to intravenous thrombolysis with intravenous thrombolysis alone.

Methods: Databases were searched for eligible randomized controlled trials. The primary outcome was a functional neurological outcome after 90 days. A secondary outcome was severe disability and death. Data were pooled in the control and intervention groups, and OR was calculated on an intention to treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I(2) (significance cut-off value >50%) with the Mantel-Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant.

Results: Six studies met the eligibility criteria, and data from 1569 patients were analyzed. A higher probability of a functional neurological outcome after 90 days was found for the intervention group (OR 2, 95% CI 2 to 3). There was a significantly higher probability of death and severe disability in the control group compared with the intervention group.

Conclusions: Endovascular treatment in addition to intravenous thrombolysis for acute ischemic stroke leads to an improved clinical outcome after 3 months, compared with patients receiving intravenous thrombolysis alone.

Keywords: Angiography; Intervention; Stent; Stroke; Thrombectomy.

Figure 1

Forest plot of the modified Rankin Scale (mRS) in the intervention and control groups. (A) OR of mRS 0–2 (functional outcome) in the intervention and control groups after 90 days. (B) OR of mRS 0–1 (excellent outcome) in the intervention and control groups after 90 days. (C) OR of mRS 0–2 (functional outcome) in the intervention and control groups after 90 days, excluding IMS-III. (D) OR of mRS 0–1 (excellent outcome) in the intervention and control groups after 90 days, excluding IMS-III. Studies: ESCAPE, Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times; EXTEND, Extending the Time for Thrombolysis in Emergency Neurological Deficits; IMS-III, Interventional Management of Stroke-III; MR CLEAN, Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands; REVASCAT, Randomized Trial of Revascularization with Solitaire FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset; SWIFT-PRIME, Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment.