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.

scholarly journals An Overview of Meta-Analyses of Endovascular Bridging Therapies for Acute Ischemic Stroke

2018 ◽  
Vol 2018 ◽  
pp. 1-12 ◽  
Author(s):  
Si-Yan Chen ◽  
Xing-Ru Zhang ◽  
Jie Chen ◽  
Wan-Qian Ge ◽  
Wen-Wen Wang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Controlled Trial ◽  
Improved Outcomes ◽  
Significant Difference ◽  
Outcome Improvement ◽  
Symptomatic Intracranial Hemorrhage ◽  
Best Medical Therapy ◽  
Meta Analyses

Background. Acute Ischemic Stroke (AIS) is a common cause of death worldwide and the leading cause of long-term severe disability. Endovascular bridging therapies (EBT), including endovascular thrombectomy (ET) and intra-arterial thrombolytic (IAT), have been recommended to realize a favorable functional outcome for AIS patients. Methods. An overview of meta-analyses of primary randomized controlled trial (RCT) studies was performed evaluating EBT for AIS patients compared with usual care. Results. Ten meta-analyses were included in this overview. ET was associated with a higher incidence of achieving functional outcome improvement, defined as a modified Rankin scale of 0 to 1 (mRS, p=0.003), 0 to 2 (p<0.00001), and 0 to 3 (p=0.005). The risk of symptomatic intracranial hemorrhage (sICH) rate and all-cause mortality were similar between the two groups. Moreover, IAT treatment was also related to significantly improved outcomes in terms of the mRS score (p<0.05), but no significant difference in rates of sICH and mortality within 90 days. Conclusions. In conclusion, our analysis supports that EBT, regardless of format (e.g., ET or IAT), is superior to the best medical therapy alone (e.g., IVT) in terms of mRS score in patients with AIS. In addition, the safety of EBT is similar to IVT.

scholarly journals Intra-arterial treatment for acute ischemic stroke: a meta-analysis

10.3823/2291 ◽  
2017 ◽  
Vol 10 ◽  
Author(s):  
Shaheen E Lakhan ◽  
McClellan M Walther ◽  
David R Morganstein ◽  
Truc Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Significant Benefit ◽  
Large Vessel ◽  
Randomized Controlled ◽  
Intravenous Tissue Plasminogen Activator ◽  
Improved Outcomes ◽  
Tissue Plasminogen ◽  
Study Heterogeneity

Objective: To assess the potential benefit of treating patients with acute ischemic stroke using intra-arterial methods. Methods: A meta-analysis of published randomized controlled trials that compared standard therapy with intravenous tissue plasminogen activator (IVtPA) for thrombolysis to intra-arterial therapies in patients with acute stroke was performed. All studies reported were analyzed as one group and studies documenting patients with large vessel obstruction were analyzed as a second group. The standardized mean difference (SMD) and the odds ratio (OR) of the dichotomized outcomes of Modified Rankin Scale (mRS) of these trials was calculated. Results: Nine trials were identified with 2,711 patients treated. Meta-analysis of all studies, with and without large vessel obstruction documented, showed a significant benefit with intra-arterial therapy (SMD: 0.22 + 0.041; P=0.003). The dichotomized outcomes of mRS of these trials showed significant improvement (OR: 1.66 -2.43 in four of the five treatment arm groups examined). Meta-analysis of all publications with large vessel obstruction documented as an entry criteria showed a greater significant benefit with intra-arterial therapy (SMD: 0.35 + 0.05; P<0.001). The dichotomized outcomes of mRS of these trials showed significant improvement (OR: 1.36 -2.38 in all five treatment arm groups examined). Some heterogeneity was observed between studies. Conclusion: Treatment of patients with acute ischemic stroke was associated with improved outcomes as measured by mRS. Patient selection, standard treatment, and study treatment factors contributed to the statistical evaluation of inter study heterogeneity and may have contributed to different study outcomes.

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.

Mechanical Thrombectomy with or without Intravenous Thrombolysis in Acute Ischemic Stroke: A Meta-Analysis for Randomized Controlled Trials

2021 ◽  
pp. 1-10
Author(s):  
Hang Li ◽  
Siyuan Yang ◽  
Yi Zhong ◽  
Jiahe Wang ◽  
Xiang Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Randomized Controlled Trials ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Controlled Trials ◽  
Efficacy And Safety ◽  
Anterior Circulation ◽  
Randomized Controlled

<b><i>Introduction:</i></b> The combination of mechanical thrombectomy (MT) and intravenous thrombolysis (IVT) is more effective than IVT alone in patients with large vessel occlusion, which has been proven in recent studies. However, there are still debates over whether IVT benefits patients treated with only direct mechanical thrombectomy (dMT). <b><i>Methods:</i></b> PubMed, Embase, and Cochrane Library were searched on June 15, 2021, for randomized controlled trials (RCTs). Seven RCTs with 2,143 patients were enrolled in our study. <b><i>Results:</i></b> MT combined with IVT had comparable efficacy and safety outcome compared with dMT in proximal anterior circulation occlusion at 90 days. For the primary outcome, pooled data showed no significant difference in the modified Rankin Scale (mRS) 0–2 at 90 days between the dMT and MT+IVT groups (pooled odds ratio 0.96, 95% confidence interval, 0.79, 1.17, <i>p</i> = 0.39). As for the mRS score 0–1 at 90 days, the degree of benefit conferred by dMT was substantial: for every 100 patients treated, the number of patients which had an excellent outcome in the dMT group was 10 higher than that of the MT+IVT group. <b><i>Conclusion:</i></b> In this meta-analysis including 7 RCTs, MT had comparable consequences to bridging treatment in efficacy and safety outcomes for patients with ischemic stroke caused by the occlusion of proximal anterior circulation, irrespective of geographical location. These findings support the adoption of dMT in acute ischemic stroke treatments and have higher cost-effectiveness in global applications.

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.

scholarly journals Direct Endovascular Thrombectomy or With Prior Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Jing Chen ◽  
Teng-Fei Wan ◽  
Tian-Ce Xu ◽  
Guo-Can Chang ◽  
Hui-Sheng Chen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Randomized Controlled Trials ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Controlled Trials ◽  
Endovascular Thrombectomy ◽  
Excellent Outcome ◽  
Randomized Controlled

Background and purpose: It is unclear whether endovascular thrombectomy alone compared with intravenous thrombolysis combination with endovascular thrombectomy can achieve similar neurological outcomes in patients with acute large vessel occlusion stroke. We aimed to perform a systematic review and meta-analysis of randomized controlled trials to compare endovascular thrombectomy alone or intravenous thrombolysis plus endovascular thrombectomy in this population.Methods: We systematically searched PubMed, Embase, and ClinicalTrials.gov. We restricted our search to randomized clinical trials that examined the clinical outcomes of endovascular thrombectomy alone vs. intravenous thrombolysis plus endovascular thrombectomy. The Cochrane risk of bias tool was used to assess study quality. Random-effects meta-analyses were used for evaluating all outcomes.Results: Total three randomized controlled trials with 1,092 individuals enrolled were included in the meta-analysis, including 543 (49.7%) who received endovascular thrombectomy alone and 549 (50.3%) who received intravenous thrombolysis plus endovascular thrombectomy. The primary outcome of 90-day functional independence (modified Rankin scale (mRS) score ≤ 2) was 44.6% (242/543) in the endovascular thrombectomy alone group vs. 42.8% (235/549) in the alteplase with endovascular thrombectomy group (odds ratio (OR), 1.08 [95% CI, 0.85–1.38]; P = 0.0539). Among pre-specified secondary outcomes, no significant between-group differences were found in excellent outcome (mRS score ≤ 1) (OR, 1.12 [95% CI, 0.85–1.47]; P = 0.418), mortality at 90 days (OR, 0.93 [95% CI, 0.68–1.29]; P = 0.673), successful reperfusion (thrombolysis in cerebral infarction 2b-3) (OR, 0.75 [95% CI, 0.54–1.05]; P = 0.099), and symptomatic intracranial hemorrhage (OR, 0.72 [95% CI, 0.45–1.15]; P = 0.171).Conclusions: Among patients with acute ischemic stroke in the anterior circulation within 4.5 h from the onset, endovascular thrombectomy alone was non-inferior to combined intravenous thrombolysis and endovascular thrombectomy.

scholarly journals Intravenous Thrombolysis Before Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta‐Analysis

2021 ◽  
Author(s):  
Houwei Du ◽  
Hanhan Lei ◽  
Gareth Ambler ◽  
Shuangfang Fang ◽  
Raoli He ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Bridging Therapy ◽  
Randomized Controlled ◽  
Symptomatic Intracranial Hemorrhage

Background Whether intravenous thrombolysis before mechanical thrombectomy provides additional benefit for functional outcome in acute ischemic stroke remains uncertain. We performed a meta‐analysis to compare the outcomes of direct mechanical thrombectomy (dMT) to mechanical thrombectomy with bridging using intravenous thrombolysis (bridging therapy [BT]) in patients with acute ischemic stroke. Methods and Results We performed a literature search in the PubMed, Excerpta Medica database, and Cochrane Central Register of Controlled Trials from January 1, 2003, to April 26, 2021. We included randomized clinical trials and observational studies that reported the 90‐day functional outcome in patients with acute ischemic stroke undergoing dMT compared with BT. The 12 included studies (3 randomized controlled trials and 9 observational studies) yielded 3924 participants (mean age, 68.0 years [SD, 13.1 years]; women, 44.2%; 1887 participants who received dMT and 2037 participants who received BT). A meta‐analysis of randomized controlled trial and observational data revealed similar 90‐day functional independence (odds ratio [OR], 1.04; 95% CI, 0.90–1.19), mortality (OR, 1.03; 95% CI, 0.78–1.36), and successful recanalization (OR, 0.93; 95% CI, 0.76–1.14) for patients treated with dMT or BT. Compared with those in the BT group, patients in the dMT group were less likely to experience symptomatic intracranial hemorrhage (OR, 0.68; 95% CI, 0.51–0.91; P =0.008) or any intracranial hemorrhage (OR, 0.71; 95% CI, 0.61–0.84; P <0.001). Conclusions In this meta‐analysis of patients with acute ischemic stroke, we found no significant differences in 90‐day functional outcome or mortality between dMT and BT, but a lower rate of symptomatic intracranial hemorrhage for dMT. These findings support the use of dMT without intravenous thrombolysis bridging therapy. Registration URL: https://www.crd.york.ac.uk/prospero/ ; Unique identifier: 42021234664.

Electroacupuncture for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

2015 ◽  
Vol 43 (08) ◽  
pp. 1541-1566 ◽  
Author(s):  
Ai-Ju Liu ◽  
Ji-Huang Li ◽  
Hui-Qin Li ◽  
Deng-Lei Fu ◽  
Lin Lu ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Index Formula ◽  
Efficacy Rate ◽  
Randomized Controlled Clinical Trials ◽  
Randomized Controlled ◽  
Significant Difference

Electroacupuncture (EA) is an extension technique of acupuncture based on traditional acupuncture combined with modern electrotherapy. Here, we conducted a systematic review specifically to assess the effectiveness and safety of EA for acute ischemic stroke. Eight databases were searched for randomized-controlled clinical trials (RCTs) of EA for acute ischemic stroke published from inception to June 2013. Ultimately, 67 studies claimed to be RCTs. Eighteen studies with 1411 individuals were selected for the analyses, which got [Formula: see text] “yes” in the domains of Cochrane risk of bias tool. The meta-analysis showed a significant effect of EA for improving Barthel Index ([Formula: see text]), Fugl–Meyer Assessment ([Formula: see text]), National Institutes of Health Stroke Scale ([Formula: see text]) and Revised Scandinavian Stroke Scale ([Formula: see text]) compared with western conventional treatments (WCTs). In an analysis of the total clinical efficacy rate, there was a significant difference between EA and WCTs ([Formula: see text]). Adverse effects were monitored in 6 studies, and were well tolerated in all stroke patients. According to the GRADE approach, the quality of evidence was mostly high or moderate. In conclusion, this systematic review revealed the evidence in support of the use of EA for acute ischemic stroke, although further larger sample-size and rigorously designed RCTs are required.

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