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. 2023 Jan 25:14:1023089.
doi: 10.3389/fneur.2023.1023089. eCollection 2023.

Rescue intracranial stenting for acute ischemic stroke after the failure of mechanical thrombectomy: A systematic review, meta-analysis, and trial sequential analysis

Junxiu Cai  1 , Hai Xu  2 , Rongzhou Xiao  3 , Liping Hu  1 , Ping Xu  4 , Xianbin Guo  1 , Yu Xie  1 , Min Pan  1 , Jie Tang  1 , Qingtao Gong  1 , Yan Liu  1 , Rong Su  1 , Jiahua Deng  5 , Li Wang  1
Affiliations

Rescue intracranial stenting for acute ischemic stroke after the failure of mechanical thrombectomy: A systematic review, meta-analysis, and trial sequential analysis

Junxiu Cai et al. Front Neurol. .

Abstract

Background: Intracranial rescue stenting (RS) might be an option for acute ischemic stroke after the failure of mechanical thrombectomy (MT). However, the findings were not consistent in previous systematic reviews, and whether the conclusion was supported by sufficient statistical power is unknown.

Aim: To examine the effect of RS on acute ischemic stroke after the failure of MT with a systematic review, meta-analysis, and trial sequential analysis (TSA).

Methods: We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 15 June 2022, without any language restriction. Studies assessing the effect of RS for acute ischemia stroke after MT failure were included. Two reviewers independently screened the retrieved articles, extracted data, and evaluated the quality of the included studies through the New Ottawa Scale (NOS). The primary outcome was the recanalization rate after RS. Secondary outcomes included modified Rankin Scale (mRS) at 3 months after stroke, symptomatic intracranial hemorrhage (sICH), and mortality rate. We synthesized the data through a random-effects model and performed a TSA analysis.

Results: We included 15 studies (containing 1,595 participants) after screening 3,934 records. The pooled recanalization rate for rescue stenting was 82% (95% CI 77-87%). Compared with non-stenting, rescue stenting was associated with a higher proportion of patients with 0-2 mRS score (OR 3.96, 95% CI 2.69-5.84, p < 0.001) and a lower 90-day mortality rate (OR 0.46, 95% CI 0.32-0.65, p < 0.001), and stenting did not increase sICH rate (OR 0.63, 95% CI 0.39-1.04, p = 0.075). The TSA analysis showed that the meta-analysis of the mRS score had a sufficient sample size and statistical power.

Conclusions: Our study showed that rescue stenting was effective and safe for patients with acute ischemia stroke who also had a failed MT, and this result was confirmed in a TSA analysis.

Keywords: acute ischemic stroke; mechanical thrombectomy failure; meta-analysis; rescue stenting; trial sequential analysis.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Recanalization rate.
Figure 2
Figure 2
The mRS score assessment. The mRS score of 0–2 indicates a good outcome of patients with ischemia stroke. (A) Summarizes the proportion of patients with 0–2 mRS scores, using data from cohorts without control groups. (B) Shows the comparison of stenting vs. non-stenting in the proportion of patients with 0–2 mRS score, and a higher OR indicates a better result of the stenting arm. mRS, modified Rankin Scale; OR, odds ratio.
Figure 3
Figure 3
The proportion of patients with sICH. sICH, symptomatic intracranial hemorrhage. sICH is a negative outcome for patients receiving rescue stenting. (A) Summarizes the proportion of patients developing sICH after receiving stenting. (B) Shows the comparison of stenting with non-stenting in the proportion of patients developing sICH, and a lower OR indicates a better result for the stenting arm. OR, odds ratio.
Figure 4
Figure 4
90-day mortality. 90-day mortality is a negative outcome for patients receiving rescue stenting. (A) Summarizes the proportion of 90-day mortality. (B) Shows the comparison of stenting with non-stenting in the proportion of 90-day mortality, and a lower OR indicates a better result for the stenting arm. OR, odds ratio.
Figure 5
Figure 5
TSA analysis on the mRS score. mRS score of 0–2 is a positive outcome for patients receiving rescue stenting. The x-axis ticks refer to the studies added sequentially into the analysis. The blue curve was the adjusted Z-curve, and it crossed the dark-red horizontal line (conventional boundary for α = 0.05). The vertical red line shows the required information size—the needed sample size for a robust result with sufficient statistical power. The analysis included 704 participants, which exceed the required information size (n = 442). mRS, modified Rankin Scale; TSA, trial sequential analysis.
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