Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis

2017 ◽  
Vol 10 (7) ◽  
pp. 620-624 ◽  
Author(s):  
Hamidreza Saber ◽  
Sandra Narayanan ◽  
Mohan Palla ◽  
Jeffrey L Saver ◽  
Raul G Nogueira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Significant Difference

BackgroundEndovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA).MethodsWe conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3.ResultsA total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0–2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0–2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42).ConclusionsThis meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.

Abstract WP1: Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent-Retriever, Aspiration, MERCI: Multi-Center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Amer M Malik ◽  
Dileep R Yavagal ◽  
Mehdi Bouslama ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Tertiary Care ◽  
Stent Retriever ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference

Introduction: Recent trials demonstrated that mechanical thrombectomy improve functional outcome in anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) of the middle cerebral artery (MCA) M1 segment. However, such data regarding AIS due to MCA M2 segment ELVO is limited. Analysis of the STAR, SWIFT, and SWIFT-PRIME trials found thrombectomy in MCA M2 occlusion to be feasible in achieving successful reperfusion. The most optimal technique and/or device used for such reperfusion is not clearly defined. We aim to compare the outcome for the contemporary techniques and devices used for thrombectomy of AIS patients due to MCA M2 ELVO. Methods: A retrospective review of AIS patients with MCA M2 ELVO receiving thrombectomy from three tertiary care academic medical centers was conducted. Thrombectomy technique and thrombectomy device utilized were recorded. Outcomes were successful angiographic reperfusion (TICI ≥2b), favorable modified Rankin Scale (mRS≤2) at discharge and at 90 days, and rate of symptomatic intracerebral hemorrhage (sICH). Results: From October 1999 through June 2016, 253 AIS patients underwent thrombectomy for MCA M2 ELVO. Thrombectomy methods utilized were Stent-retriever (n=118), Aspiration only [manual or Penumbra device] (n=83), and MERCI retriever (n=52). Table 1 shows rate of outcomes measured. There was no difference in baseline NIHSS or in stroke onset to groin puncture time. Stent-retriever group showed a significantly higher recanalization rate, lower sICH rate, and favorable 90-day mRS versus Aspiration group or MERCI group, respectively. No significant difference was seen in discharge mRS between the groups. Conclusions: Thrombectomy for AIS patients with MCA M2 ELVO with Stent-retriever appears to be feasible with a significantly higher rate of recanalization, lower sICH rate, and favorable 90-day mRS when compared to Aspiration and MERCI.

Abstract P528: Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy a Meta-Analysis

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Grace K Lee ◽  
Vanessa Chen ◽  
Choon Han Tan ◽  
Aloysius Leow ◽  
Anil Gopinathan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Risk Ratio ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Adjunctive Treatment ◽  
Mortality Data ◽  
Vessel Occlusion ◽  
Safety And Efficacy ◽  
Significant Difference

Introduction and hypothesis: In patients with acute ischemic stroke with large vessel occlusion (AIS-LVO), the role of intra-arterial adjunctive medications (IAM) like urokinase, tPA or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We hypothesize that AIS-LVO patients treated with both MT + IAM (rescue or concurrent) achieve better safety and efficacy outcomes than patients treated with MT alone and aim to determine the efficacy and safety of concomitant or rescue IAM for AIS-LVO patients undergoing MT. Methods: We searched Medline, Embase and Cochrane Stroke Group Trials Register databases from inception until 13th March 2020. We analysed all studies with patients diagnosed with AIS-LVO in the anterior or posterior circulation, that provided data for the two treatment arms: 1)MT+IAM and 2)MT-only, and also reported on at least one of the following outcomes: reperfusion, 90-days modified Rankin Scale (mRS), symptomatic intracranial hemorrhage (sICH) and 90-days mortality. Data were collated in accordance with the PRISMA guidelines. Results: Sixteen non-randomized observational studies with a total of 4581 patients were analysed. MT-only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT+IAM. As compared to patients treated with MT alone, patients treated with combination therapy (MT +IAM) had a higher likelihood of achieving good functional outcome (risk ratio=1.13, 95% CI 1.03-1.24) and a lower risk of 90-day mortality (risk ratio=0.82, 95% CI 0.72-0.94). There was no significant difference in successful reperfusion (risk ratio=1.02, 95% CI 0.99-1.06) and sICH between the two groups (risk ratio = 1.13, 95% CI 0.87-1.46) (Figure 1). Conclusions: In AIS-LVO, use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to confirm the safety and efficacy of IAM as adjunctive treatment of MT.

scholarly journals Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Hubert Lee ◽  
Ayman M. Qureshi ◽  
Nils H. Mueller-Kronast ◽  
Osama O. Zaidat ◽  
Michael T. Froehler ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Systematic Evaluation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature.Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol.Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75–6.63], p < 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09–1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26–0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0–2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51–7.34%, I2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]).Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.

Abstract P539: Comparison of Transradial Artery versus Transfemoral Artery Access for Solumbra Technique in Mechanical Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Taha Nisar ◽  
Jimmy Patel ◽  
Muhammad Z Memon ◽  
Amit Singla ◽  
Priyank Khandelwal
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Arrival Time ◽  
Mechanical Thrombectomy ◽  
Retrospective Chart Review ◽  
Functional Independence ◽  
Binary Logistic Regression Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients

Introduction: Solumbra technique involves the simultaneous use of stent-retriever and large-bore aspiration for clot retrieval in mechanical thrombectomy (MT). We aim to compare various time parameters in patients who undergo MT via solumbra technique via transradial artery (TRA) approach vs. transfemoral artery (TRF) approach. Methods: We performed a retrospective chart review of patients who underwent MT via solumbra technique for anterior circulation large vessel occlusion at a comprehensive stroke center from 7/2014 to 5/2020. We compared time to recanalization parameters, score of TICI≥2b, and functional independence (3-month mRS≤2) in patients who underwent MT via TRA vs.TRF approach via the solumbra technique. A binary logistic regression analysis was performed, controlling for age, sex, pre-treatment-NIHSS, type of anesthesia (general vs.moderate), laterality, and clot location [proximal (internal carotid or M1 segment of the middle cerebral artery) vs.distal (M2 or M3 segment of the middle cerebral artery)]. Results: A total of 98 patients met our inclusion criteria. The mean age was 63.59±14.40 years. 18 (18.37%) patients underwent MT through transradial approach. In our cohort, there was a significant association of TRA with shorter angio suite arrival-time to puncture-time (22.12±9.92mins vs.28.83±12.26mins; OR, 0.94; 95% CI, 0.88-1; P 0.026), but not with puncture-time to recanalization-time (84.34±61.34mins vs.63.73±35.29mins; OR, 1.01; 95% CI, 1-1.03; P 0.085), angio suite arrival-time to recanalization-time (103.12±51.29mins vs.93.42±39.08mins; OR, 1.01; 95% CI, 1-1.02; P 0.524), number of passes to recanalization (1.78±1.36 vs.1.68±1.05; OR, 1.03; 95% CI, 0.66-1.63 ; P 0.899), number of patients with TICI≥2b (83.34% vs.91.25%; OR, 0.68; 95% CI, 0.14-3.4; P 0.633), and functional independence (66.67% vs.78.75%; OR, 0.49; 95% CI, 0.13-1.86; P 0.292), when compared to TRF approach for MT using solumbra technique. Conclusion: Our study demonstrates a significant association between TRA approach with shorter angio suite arrival-time to puncture-time but not with overall time to recanalization, number of patients with TICI≥2b, and functional independence, when compared to TRF approach for MT using solumbra technique.

Abstract P488: The Impact of First Pass Effect on Acute Ischemic Stroke Clinical Outcomes: Why We Need to Continue to Improve Mechanical Thrombectomy?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Mahmoud Dibas ◽  
Amr Ehab El-Qushayri ◽  
Sherief Ghozy ◽  
Adam A Dmytriw ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Improved Outcomes ◽  
First Pass ◽  
The Impact

Background: Mechanical thrombectomy (MT) has significantly improved outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). The first-pass effect (FPE), defined as achieving complete reperfusion (mTICI3/2c) with a single pass, was reported to be associated with higher functional independence rates following EVT and has been emphasized as an important procedural target. We compared MT outcomes in patients who achieved FPE to those who did not in a real world large database. Method: A retrospective analysis of LVO pts who underwent MT from a single center prospectively collected database. Patients were stratified into those who achieved FPE and non-FPE. The primary outcome (discharge and 90 day mRS 0-2) and safety (sICH, mortality and neuro-worsening) were compared between the two groups. Results: Of 580 pts, 261 (45%) achieved FPE and 319 (55%) were non-FPE. Mean age was (70 vs 71, p=0.051) and mean initial NIHSS (16 vs 17, p=0.23) and IV tPA rates (37% bs 36%, p=0.9) were similar between the two groups. Other baseline characteristics were similar. Non-FPE pts required more stenting (15% vs 25%, p=0.003), and angioplasty (19% vs 29%, p=0.01). The FPE group had significantly more instances of discharge (33% vs 17%, p<0.001), and 90-day mRS score 0-2 (29% vs 20%, p<0.001), respectively. Additionally, the FPE group had a significant lower mean discharge NIHSS score (12 vs 17, p<0.001). FPE group had better safety outcomes with lower mortality (14.2% vs 21.6%, p=0.03), sICH (5.7% vs 13.5, p=0.004), and neurological worsening (71.3% vs 78.4%, p=0.02), compared to the non-FPE group. Conclusion: Patients with first pass complete or near complete reperfusion with MT had higher functional independence rates, reduced mortality, symptomatic hemorrhage and neurological worsening. Improvement in MT devices and techniques is vital to increase first pass effect and improve clinical outcomes.

Abstract WP25: The Impact of Body Mass Index on Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Stephanie Chen ◽  
David McCarthy ◽  
Vasu Saini ◽  
Marie Brunet ◽  
Eric Peterson ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Body Mass ◽  
Linear Correlation ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Normal Weight ◽  
Vessel Occlusion ◽  
The Impact

Background: Obesity is an established risk factor for acute ischemic stroke (AIS), but its impact on clinical outcomes and mortality after AIS remains controversial. In this study, we evaluate the association of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS). Methods: We reviewed our prospective MT database for LVOS between 2015 and 2018. BMI was analyzed as a continuous and categorical variable with underweight BMI <18.5, normal BMI 18.5-24.9, overweight BMI 25-29.9, and obese BMI>30. Multivariate analysis was used to determine predictors of outcome. Results: 335 patients underwent MT with 7 (2.1%) patients classified as underweight, 107 (31.9%) normal, 141 (42.1%) overweight, and 80 (23.9%) obese. Compared to normal weight (reference), obese patients had higher rates of hypertension and hyperlipidemia, while underweight patients had higher rates of previous stroke and presentation NIHSS. The time from symptom onset to puncture, procedural techniques, and reperfusion success (>TICI 2b) was not significantly different between BMI categories. There was a significant inverse linear correlation between BMI and symptomatic hemorrhagic. In patients with successful reperfusion (>TICI 2b), there was also a significant bell-shaped relationship between BMI and functional independence (mRS < 3) with both low and high BMIs associated with worse outcomes. In patients without post-procedural symptomatic hemorrhage, there was a significant linear correlation between BMI and inpatient mortality. Conclusion: In LVOS patients treated with MT, BMI is inversely related with post-procedural symptomatic hemorrhage. Yet in those whom reperfusion is achieved, both lower and higher than normal BMI were associated with worse functional outcomes. Thus, the obesity paradox does not appear to pertain to mechanical thrombectomy, although larger prospective studies are necessary.

Abstract WMP1: Cost Effectiveness Analysis of Mechanical Thrombectomy: the THRACE Randomized Trial

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Hamza Achit ◽  
Francis guillemin ◽  
Marc Soudant ◽  
Kossar Hosseini ◽  
Aurelie Bannay ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Randomized Trial ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Cost Effective ◽  
Functional Independence ◽  
Quality Adjusted Life Year ◽  
Significant Difference ◽  
Quality Adjusted Life

Background and purpose: The benefit of mechanical thrombectomy added to intravenous thrombolysis in patients with acute ischemic stroke has been largely demonstrated. However, evidence on economic incentive of this strategy is still limited, especially in the context of randomized trial. The purpose of this study is to analyze whether the combination of mechanical thrombectomy with intravenous thrombolysis is more cost-effective than implementing intravenous thrombolysis alone. Patients and methods: Individual-level cost and outcome data were collected in the THRACE randomized clinical trial, including patients with acute ischaemic stroke and proximal cerebral artery occlusion. Patients were assigned to either intravenous thrombolysis (IVT; n = 208) or intravenous thrombolysis plus intra-arterial thrombectomy (IVMT; n=204). The primary outcomes were both modified Rankin scale of functional independence at 90 days (score 0-2) and the EuroQol-5D score of quality of life. This study considered the perspective of the National Health Security System in France. Results: Bridging therapy increased by 10.9% the rate of functional independence compared to IVT (53% vs 42,1%) at an increased cost of 1909 є, with no significant difference in mortality (12% vs 13%) or symptomatic intracranial haemorrhage (2% vs 2%). Cost per one averted case of disability was consequently estimated at 17,480 є. The incremental cost per quality-adjusted life year gained was 13,423 є. Sensitivity analysis showed that combined approach had 84.1% probability of being cost-effective regarding cases of averted disability and 92.2% probability regarding quality-adjusted life year outcome. The national implementation of this new strategy would result in additional cost of 12.9 million є and avoid about 737 cases of death or disability. Conclusions: Based on randomized trial, this study demonstrates that intravenous thrombolysis plus mechanical intra-arterial thrombectomy for treating acute ischemic stroke is more cost-effective than intravenous thrombolysis alone.

369 The TREVO Registry-Subgroup Analysis, Treatment Beyond 6 Hours

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 286-286
Author(s):  
Mandy Jo Binning ◽  
Erol Veznedaroglu ◽  
Ronald Budzik ◽  
Joey English ◽  
Blaise Baxter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Symptom Onset ◽  
Subgroup Analysis ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Real World Data ◽  
Vessel Occlusion ◽  
Significant Difference

Abstract INTRODUCTION Current randomized trials demonstrating superiority of mechanical thrombectomy for the treatment of acute ischemic stroke for anterior circulation large vessel occlusion, have enrolled patients with symptom onset up to 6 hours. Outcomes of thrombectomy beyond 6 hours have not been well studied. The Trevo Registry is designed to assess real world outcomes of the Trevo Retriever in patients experiencing acute ischemic stroke. Trevo registry has currently enrolled 1431 patients with 90-day outcome data. Outcomes of patients treated beyond 6 hours of symptom onset were studied. METHODS The study design is a prospective, open-label, consecutive enrollment, multi-center, global registry of all patients who undergo mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Enrollment is expected to reach 2000 subjects at up to 100 sites. Subgroup analysis of enrolled patients treated beyond 6 hours of symptom onset and with 90-day follow-up was performed. RESULTS >As of March 24, 2017, a total of 1846 total patients were enrolled. Median NIHSS at admission was 15.5 (IQR 11–20). The majority of patients (67.4%) were treated at 6 hours or less from last known normal with a median procedure time of 50 minutes (8-286 minutes). In patients treated after 6 hours from time last known well, the revascularization rate was 93.7% with symptomatic ICH of 1.8% and 90-day mRS = 2 was 51.8%. Subgroup analysis of patients presenting within 6 hours and those presenting beyond 6 hours showed no significant difference in patient demographics or medical comorbidities. There was no difference in complication rate or 90-day outcome between the two groups. CONCLUSION The Trevo Retriever Registry represents the first look at real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. This data represents real world use of the Trevo Retriever including those treated beyond 6 hours after stroke symptoms (33.8%), and this data adds to the results from recent trials with restricted eligibility criteria.

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.

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