Thrombolysis in Cerebral Infarction Grade 2C or 3 Represents a Better Outcome than 2B for Endovascular Thrombectomy in Acute Ischemic Stroke: A Network Meta-Analysis

2020 ◽  
Vol 136 ◽  
pp. e419-e439
Author(s):  
Kyoung Min Jang ◽  
Taek Kyun Nam ◽  
Myeong Jin Ko ◽  
Hyun Ho Choi ◽  
Jeong Taik Kwon ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Endovascular Thrombectomy

Abstract WP12: Endovascular Thrombectomy for Acute Ischemic Stroke Associated With Cervical Artery Dissection: A Systematic Review and Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Adam A Dmytriw ◽  
Julian Maingard ◽  
Kevin Phan ◽  
Rajph J Mobbs ◽  
Mark Brooks ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Artery Dissection ◽  
Cervical Artery Dissection ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Cervical Artery

Objectives: Strokes associated with cervical artery dissection have been managed primarily with antithrombotics with poor outcomes. The additive role of endovascular thrombectomy remains unclear. The objective was to perform systematic review and meta-analysis to compare endovascular thrombectomy and medical therapy for acute ischemic stroke associated with cervical artery dissection. Methods: Studies from six electronic databases included outcomes of patient cohorts with acute ischemic stroke secondary to cervical artery dissection who underwent treatment with endovascular thrombectomy. A meta-analysis of proportions was conducted with a random-effects model. Modified Rankin score at 90 days (mRS 0-2) was the primary outcome. Other outcomes included proportion of patients with thrombolysis in cerebral infarction (TICI) 2b-3 flow, 90-day mortality rate, and 90-day symptomatic intracerebral hemorrhage (sICH) rate. Results: Six studies were included, comprising 193 cases that underwent thrombectomy compared with 59 cases that were managed medically. Successful recanalization with a pooled proportion of thrombolysis in cerebral infarction (TICI) 2b-3 flow in the thrombectomy group was 74%. Favorable outcome (mRS 0-2) was superior in the pooled thrombectomy group (62.9%, 95% CI 55.8-69.5%) compared medical management (41.5%, 95% CI 29.0-55.1%, P=0.006). The pooled rate of 90-day mortality was similar for endovascular vs medical (8.6% vs 6.3%). The pooled rate of symptomatic intracranial haemorrhage (sICH) did not significantly differ (5.9% vs 4.2%, P=0.60). Conclusions: Current data suggest that endovascular thrombectomy may be an option in patients with acute ischemic stroke due to cervical artery dissection. This requires further confirmation in higher quality prospective studies.

EXPRESS: Impact of renal impairment on short-term outcomes following endovascular thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

2021 ◽  
pp. 174749302110473
Author(s):  
Jin Pyeong Jeon ◽  
Chih-Hao Chen ◽  
Fon-Yih Tsuang ◽  
Jianming Liu ◽  
Michael D Hill ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Renal Impairment ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Functional Independence ◽  
Continuous Variable ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage ◽  
The Impact

Background. The impact of renal impairment (RI) on the outcomes of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) was relatively limited and contradictory. We performed a systematic review and meta-analysis to investigate this. Aims. We registered a protocol on September 2020 and searched MEDLINE, EMBASE, and Google Scholar accordingly. RI was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. Predefined outcomes included functional independence (defined as a modified Rankin Scale of 0, 1, or 2) at 3 months, successful reperfusion, mortality, and symptomatic intracerebral hemorrhage (sICH). Summary of review. Eleven studies involving 3453 patients were included. For the unadjusted outcomes, RI was associated with fewer functional independence (odds ratio (OR), 0.49; 95% confidence interval (CI), 0.39–0.62) and higher mortality (OR, 2.55; 95% CI, 2.03–3.21). RI was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63–1.00) and sICH (OR, 1.41; 95% CI, 0.95–2.10). For the adjusted outcomes, results derived from a multivariate meta-analysis were consistent with the respective unadjusted outcomes: functional independence (OR, 0.59; 95% CI, 0.45–0.77), mortality (OR, 2.23, 95% CI, 1.45–3.43), and sICH (OR, 1.34; 95% CI, 0.85–2.10). Conclusions. We presented the first systematic review to demonstrate that RI is associated with fewer functional independence and higher mortality. Future EVT studies should publish complete renal eGFR data to facilitate prognostic studies and permit eGFR to be analyzed in a continuous variable. Systematic Review Registration: PROSPERO CRD42020191309

scholarly journals Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials

2021 ◽  
pp. neurintsurg-2021-017667
Author(s):  
Chun-Hsien Lin ◽  
Jeffrey L Saver ◽  
Bruce Ovbiagele ◽  
Wen-Yi Huang ◽  
Meng Lee
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Randomized Trials ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Risk Difference ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage

ObjectiveTo conduct a meta-analysis of randomized trials to comprehensively compare the effect of endovascular thrombectomy (EVT) versus intravenous thrombolysis (IVT) plus EVT on functional independence (modified Rankin Scale (mRS) 0–2) after acute ischemic stroke due to large vessel occlusions (AIS-LVO).MethodsWe searched Pubmed, EMBASE, CENTRAL, and clinicaltrials.gov from January 2000 to February 2021 and abstracts presented at the International Stroke Conference in March 2021 to identify trials comparing EVT alone versus IVT plus EVT in AIS-LVO. Five non-inferiority margins established in the literature were assessed: −15%, −10%, −6.5%, −5%, and −1.3% for the risk difference for functional independence at 90 days.ResultsFour trials met the selection criteria, enrolling 1633 individuals, with 817 participants randomly assigned to EVT alone and 816 to IVT plus EVT. Crude cumulative rates of 90-day functional independence were 46.0% with EVT alone versus 45.5% with IVT plus EVT. Pooled results showed the risk difference of functional independence was 1% (95% CI −4% to 5%) between EVT alone versus IVT plus EVT. The lower 95% CI bound of −4% fell within the non-inferiority margins of −15%, −10%, −6.5%, and −5%, but not −1.3%. Pooled results also showed the risk difference between EVT alone versus IVT plus EVT was 1% (95% CI −3% to 5%) for mRS 0–1, and 1% (95% CI −1% to 3%) for symptomatic intracranial hemorrhage.ConclusionsThis meta-analysis suggests that EVT alone is non-inferior to IVT plus EVT for several, but not the most stringent, non-inferiority margins.

Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis

2018 ◽  
Vol 11 (5) ◽  
pp. 443-449 ◽  
Author(s):  
Kevin Phan ◽  
Adam A Dmytriw ◽  
Declan Lloyd ◽  
Julian M Maingard ◽  
Hong Kuan Kok ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Endovascular Thrombectomy ◽  
Treatment Groups ◽  
Randomized Controlled ◽  
Improved Outcomes ◽  
Significant Difference ◽  
Meta Analyses

ObjectivesThe present Bayesian network meta-analysis aimed to compare the various strategies for acute ischemic stroke: direct endovascular thrombectomy within the thrombolysis window in patients with no contraindications to thrombolysis (DEVT); (2) direct endovascular thrombectomy secondary to contraindications to thrombolysis (DEVTc); (3) endovascular thrombectomy in addition to thrombolysis (IVEVT); and (4) thrombolysis without thrombectomy (IVT).MethodsSix electronic databases were searched from their dates of inception to May 2017 to identify randomized controlled trials (RCTs) comparing IVT versus IVEVT, and prospective registry studies comparing IVEVT versus DEVT or IVEVT versus DEVTc. Network meta-analyses were performed using ORs and 95% CIs as the summary statistic.ResultsWe identified 12 studies (5 RCTs, 7 prospective cohort) with a total of 3161 patients for analysis. There was no significant difference in good functional outcome at 90 days (modified Rankin Scale score ≤2) between DEVT and IVEVT. There was no significant difference in mortality between all treatment groups. DEVT was associated with a 49% reduction in intracranial hemorrhage (ICH) compared with IVEVT (OR 0.51; 95% CI 0.33 to 0.79), due to reduction in rates of asymptomatic ICH (OR 0.47; 95% CI 0.29 to 0.76). Patients treated with DEVT had higher rates of reperfusion compared with IVEVT (OR 1.73; 95% CI 1.04 to 2.94).ConclusionsTo our knowledge, this is the first network meta-analysis to be performed in the era of contemporary mechanical thrombectomy comparing DEVT and DEVTc. Our analysis suggests the addition of thrombolysis prior to thrombectomy for large vessel occlusions may not be associated with improved outcomes.

Abstract 145: Endovascular Thrombectomy for Large Vessel Ischemic Stroke Patients With Low Aspects: A Systematic Review and Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jose Danilo Diestro ◽  
Adam Dmytriw ◽  
Gabriel Broocks ◽  
Andrew Kemmling ◽  
Karen Chen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Statistical Significance ◽  
Large Vessel ◽  
Cochrane Central Register ◽  
Large Core ◽  
Stroke Patients ◽  
Endovascular Thrombectomy

Background: Most trials for the endovascular thrombectomy (EVT) of large vessel ischemic stroke excluded patients with large core infarcts and low Alberta Stroke Program Early CT Score (ASPECTS). As a result, the current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of EVT for patients with an ASPECTS of 6 or more. However recent data from the HERMES collaboration has shown that even stroke patients with large core infarcts may still benefit from EVT. Objectives: Through this systematic review, we aim to determine the safety and efficacy of EVT for large vessel ischemic stroke patients with low ASPECTS (5 or less). Methods: Medline, Cochrane Central Register of Systematic Reviews and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS acute ischemic stroke patients. Patients with low ASPECTS who underwent EVT were compared to those who only received best medical therapy (BMT). A meta-analysis of proportions was done to compare the outcomes of the two groups in terms of symptomatic intracranial hemorrhage, mortality and good 3-month functional outcomes (modified Rankin Scale < 2). Results: Nine studies with a total of 1,196 acutes stroke patients with low ASPECTS (712 undergoing EVT and 484 with only BMT) were included in the study. There was a trend towards a higher rate of sICH in the EVT group (9.2%; 95% CI 6.1% to 13.6%; I 2 53.37%) compared to the BMT group (5.5%; 95% CI 3.7% to 8.1%; I 2 =0%) but this did not reach statistical significance (p=0.11). There was no difference (p=0.41) in the pooled 3-month mortality of EVT patients (30.7%; 95% CI 21.7 to 41.5%; I 2 84.23%) and BMT patients (36.6%; 95% CI 26.4% to 48.1%; I 2 76.2%). Patients who underwent EVT had significantly better (p=0.001) 3-month outcomes, with 27.7% (95% 21.8 to 34.5%; I 2 62.08%) of patients attaining an MRS 0-2 compared to only 3.7% (95% 2.3 to 5.9%; I 2 87.21%) of patients in the BMT. Conclusion: Our meta-analysis suggests that acute stroke patients with low ASPECTS score may still benefit from EVT. Larger registry based studies and randomized controlled trials are needed to further substantiate the findings of our review.

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