Endovascular vs medical management of acute ischemic stroke

Abstract

Objective: To compare the outcomes between endovascular and medical management of acute ischemic stroke in recent randomized controlled trials (RCT).

Methods: A systematic literature review was performed, and multicenter, prospective RCTs published from January 1, 2013, to May 1, 2015, directly comparing endovascular therapy to medical management for patients with acute ischemic stroke were included. Meta-analyses of modified Rankin Scale (mRS) and mortality at 90 days and symptomatic intracranial hemorrhage (sICH) for endovascular therapy and medical management were performed.

Results: Eight multicenter, prospective RCTs (Interventional Management of Stroke [IMS] III, Local Versus Systemic Thrombolysis for Acute Ischemic Stroke [SYNTHESIS] Expansion, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy [MR RESCUE], Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands [MR CLEAN], Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness [ESCAPE], Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial [EXTEND-IA], Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment [SWIFT PRIME], and Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours [REVASCAT]) comprising 2,423 patients were included. Meta-analysis of pooled data demonstrated functional independence (mRS 0-2) at 90 days in favor of endovascular therapy (odds ratio [OR] = 1.71; p = 0.005). Subgroup analysis of the 6 trials with large vessel occlusion (LVO) criteria also demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.23; p < 0.00001). Subgroup analysis of the 5 trials that primarily utilized stent retriever devices (≥70%) in the intervention arm demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.39; p < 0.00001). No difference was found for mortality at 90 days and sICH between endovascular therapy and medical management in all analyses and subgroup analyses.

Conclusions: This meta-analysis provides strong evidence that endovascular intervention combined with medical management, including IV tissue plasminogen activator for eligible patients, improves the outcomes of appropriately selected patients with acute ischemic stroke in the setting of LVO.

Figure 1. Functional independence (mRS 0–2) and mortality (mRS 6) at 90 days and sICH after endovascular vs medical management of AIS stratified by LVO criteria

Forest plot of odds ratios (ORs) for (A) functional independence (modified Rankin Scale [mRS] 0–2) at 90 days, (B) mortality (mRS 6) at 90 days, and (C) symptomatic intracranial hemorrhage (sICH) for endovascular versus medical management of acute ischemic stroke (AIS). The included trials are divided into subgroups: trials with large vessel occlusion (LVO) criteria and trials without LVO criteria. The estimated OR and 95% confidence interval (CI) of each included study is represented by the center of the squares and the horizontal line, respectively. The summary OR and 95% CI are shown in bold, and are represented by solid diamond. Tests of heterogeneity and overall effect are given below the summary statistics. ESCAPE = Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; EXTEND-IA = Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial; IMS III = Interventional Management of Stroke III; M-H = Mantel-Haenszel; MR CLEAN = Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; MR RESCUE = Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy; REVASCAT = Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours; SWIFT PRIME = Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment; SYNTHESIS = Local Versus Systemic Thrombolysis for Acute Ischemic Stroke.

Figure 2. Functional independence (mRS 0–2) and mortality (mRS 6) at 90 days and sICH after endovascular vs medical management of AIS stratified by use of stent retriever device

Forest plot of odds ratios (ORs) for (A) functional independence (modified Rankin Scale [mRS] 0–2) at 90 days, (B) mortality (mRS 6) at 90 days, and (C) symptomatic intracranial hemorrhage (sICH) for endovascular versus medical management of acute ischemic stroke (AIS). The included trials are divided into subgroups: trials that used stent retriever device for ≥70% of endovascular therapies and trials that used stent retriever device for <70% of endovascular therapies. The estimated OR and 95% confidence interval (CI) of each included study is represented by the center of the squares and the horizontal line, respectively. The summary OR and 95% CI are shown in bold, and are represented by solid diamond. Tests of heterogeneity and overall effect are given below the summary statistics. ESCAPE = Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; EXTEND-IA = Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial; IMS III = Interventional Management of Stroke III; M-H = Mantel-Haenszel; MR CLEAN = Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; MR RESCUE = Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy; REVASCAT = Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours; SWIFT PRIME = Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment; SYNTHESIS = Local Versus Systemic Thrombolysis for Acute Ischemic Stroke.