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Meta-Analysis
. 2016 Apr 18:353:i1754.
doi: 10.1136/bmj.i1754.

Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis

Filipe Brogueira Rodrigues  1 , Joana Briosa Neves  2 , Daniel Caldeira  3 , José M Ferro  4 , Joaquim J Ferreira  5 , João Costa  6
Affiliations
Meta-Analysis

Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis

Filipe Brogueira Rodrigues et al. BMJ. .

Abstract

Objectives: To evaluate the efficacy and safety of endovascular treatment, particularly adjunctive intra-arterial mechanical thrombectomy, in patients with ischaemic stroke.

Design: Systematic review and meta-analysis.

Data sources: Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, SciELO, LILACS, and clinical trial registries from inception to December 2015. Reference lists were crosschecked.

Eligibility criteria for selecting studies: Randomised controlled trials in adults aged 18 or more with ischaemic stroke comparing endovascular treatment, including thrombectomy, with medical care alone, including intravenous recombinant tissue plasminogen activator (rt-PA). Trial endpoints were functional outcome (modified Rankin scale scores of ≤2) and mortality at 90 days after onset of symptoms. No language or time restrictions applied.

Results: 10 randomised controlled trials (n=2925) were included. In pooled analysis endovascular treatment, including thrombectomy, was associated with a higher proportion of patients experiencing good (modified Rankin scale scores ≤2) and excellent (scores ≤1) outcomes 90 days after stroke, without differences in mortality or rates for symptomatic intracranial haemorrhage, compared with patients randomised to medical care alone, including intravenous rt-PA. Heterogeneity was high among studies. The more recent studies (seven randomised controlled trials, published or presented in 2015) proved better suited to evaluate the effect of adjunctive intra-arterial mechanical thrombectomy on its index disease owing to more accurate patient selection, intravenous rt-PA being administered at a higher rate and earlier, and the use of more efficient thrombectomy devices. In most of these studies, more than 86% of the patients were treated with stent retrievers, and rates of recanalisation were higher (>58%) than previously reported. Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies. All trials were open label. Risk of bias was moderate across studies. The full results of two trials are yet to be published.

Conclusions: Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.

Systematic review registration: PROSPERO CRD42015019340.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that: no author has support for the submitted work; JJF has speaker and consultant relationships with GlaxoSmithKline, Novartis, TEVA, Lundbeck, Solvay, Abbott, Bial, Merck-Serono, Grunenthal, and Merck Sharp and Dohme that might have an interest in the submitted work in the previous three years; their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and FBR, JBN, DC, and JC have no non-financial interests that may be relevant to the submitted work. JMF received in the past three years speaker fees from Boehringer Ingelheim and consultancy fees from Boehringer Ingelheim, Lundbeck, and Daichi Sankyo.

Figures

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Fig 1 Study flow selection
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Fig 2 Risk of bias summary
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Fig 3 Forest plot for a good functional outcome (modified Rankin scale core ≤2) at 90 days, including subgroup analysis by year of study publication. AIMT=adjunctive intra-arterial mechanical thrombectomy
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Fig 4 Forest plot for mortality at 90 days, including subgroup analysis by year of study publication. AIMT=adjunctive intra-arterial mechanical thrombectomy
See this image and copyright information in PMC

Comment in

References

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