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Meta-Analysis
. 2019 Jan;11(1):20-27.
doi: 10.1136/neurintsurg-2018-013834. Epub 2018 Apr 28.

Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis

Johannes Kaesmacher  1   2 , Pasquale Mordasini  2 , Marcel Arnold  1 , Elena López-Cancio  3 , Neus Cerdá  4 , Tobias Boeckh-Behrens  5 , Justus F Kleine  6 , Mayank Goyal  7 , Michael D Hill  8 , Vitor Mendes Pereira  9 , Jeffrey L Saver  10 , Jan Gralla  2 , Urs Fischer  1
Affiliations
Meta-Analysis

Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis

Johannes Kaesmacher et al. J Neurointerv Surg. 2019 Jan.

Abstract

Background: Whether pretreatment with intravenous thrombolysis prior to mechanical thrombectomy (IVT+MTE) adds additional benefit over direct mechanical thrombectomy (dMTE) in patients with large vessel occlusions (LVO) is a matter of debate.

Methods: This study-level meta-analysis was presented in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled effect sizes were calculated using the inverse variance heterogeneity model and displayed as summary Odds Ratio (sOR) and corresponding 95% confidence interval (95% CI). Sensitivity analysis was performed by distinguishing between studies including dMTE patients eligible for IVT (IVT-E) or ineligible for IVT (IVT-IN). Primary outcome measures were functional independence (modified Rankin Scale≤2) and mortality at day 90, successful reperfusion, and symptomatic intracerebral hemorrhage.

Results: Twenty studies, incorporating 5279 patients, were included. There was no evidence that rates of successful reperfusion differed in dMTE and IVT+MTE patients (sOR 0.93, 95% CI 0.68 to 1.28). In studies including IVT-IN dMTE patients, patients undergoing dMTE tended to have lower rates of functional independence and had higher odds for a fatal outcome as compared with IVT+MTE patients (sOR 0.78, 95% CI 0.61 to 1.01 and sOR 1.45, 95% CI 1.22 to 1.73). However, no such treatment group effect was found when analyses were confined to cohorts with a lower risk of selection bias (including IVT-E dMTE patients).

Conclusion: The quality of evidence regarding the relative merits of IVT+MTE versus dMTE is low. When considering studies with lower selection bias, the data suggest that dMTE may offer comparable safety and efficacy as compared with IVT+MTE. The conduct of randomized-controlled clinical trials seems justified.

Keywords: stroke; thrombectomy; thrombolysis.

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Conflict of interest statement

Competing interests: Related: UF and JG are global PIs for the SWIFT DIRECT trial and are consultants for Medtronic. VMP is a PI for the SWIFT DIRECT trial and is a consultant for Medtronic. Unrelated: MA received honoraria for lectures and advisory boards from Bayer, Boehringer Ingelheim, Bristol Meyer Squibbs, Pfizer, and Covidien. MG is a consultant for Medtronic, Stryker, Microvention/ and Ablynx and received grants from Medtronic and Stryker provided to the University of Calgary. He has a licensing agreement with GE for systems of stroke diagnosis. MDH received a grant from Alberta Innovates for stroke program in Alberta. VMP is a consultant for Stryker (SC for DAWN trial), Penumbra (SC for PROMISE study), BALT (proctorship of products unrelated to ischemic stroke), Phenox, Rapid Medical, Neurovasc and receives research a grant from Philips. JLS is a consultant about trial design and conduct for Covidien and Stryker, and employee of the University of California, which holds a patent on retriever devices for stroke. JG is a global PI of STAR, CEC member of the PROMISE study (Penumbra), Consultancy; and receives SNSF grants for magnetic resonance imaging in stroke. UF receives research grants from Swiss National Science Foundation (SNSF). All other authors have nothing to disclose.

Figures

Figure 1
Figure 1
Summary OR of dMTE patients for day 90 mRS ≤2. *matched-pair analysis; IVT-E, IVT-eligible dMTE patients; IVT-IN, IVT-ineligible dMTE patients.
Figure 2
Figure 2
Summary OR of dMTE patients for fatal outcome at day 90. *matched-pair analysis; IVT-E, IVT-eligible dMTE patients; IVT-IN, IVT-ineligible dMTE patients.
Figure 3
Figure 3
Summary OR of dMTE patients for successful reperfusion. *matched-pair analysis; IVT-E, IVT-eligible dMTE patients; IVT-IN, IVT-ineligible dMTE patients.
Figure 4
Figure 4
Summary OR of dMTE patients for symptomatic intracerebral hemorrhage. *matched-pair analysis; IVT-E, IVT-eligible dMTE patients; IVT-IN, IVT-ineligible dMTE patients.
See this image and copyright information in PMC

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