scholarly journals Intravenous thrombolysis with 0.9 mg/kg alteplase for acute ischaemic stroke: a network meta-analysis of treatment delay

2019 ◽  
Vol 96 (1141) ◽  
pp. 680-685
Author(s):  
Xi Chen ◽  
Yu Shen ◽  
Chengfang Huang ◽  
Yu Geng ◽  
Yunxian Yu
Keyword(s):  
Ischaemic Stroke ◽  
Intracerebral Haemorrhage ◽  
Acute Ischaemic Stroke ◽  
Meta Analysis ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Treatment Delay ◽  
Cochrane Library ◽  
Randomised Controlled ◽  
Symptomatic Intracerebral Haemorrhage

ObjectivesThe aim of this study was to evaluate the effect of alteplase in intravenous thrombolysis of acute ischaemic stroke (AIS) regarding the different time windows of treatment (<3 hours, 3–4.5 hours, >4.5 hours).MethodsA systematic literature search was conducted from PubMed, Cochrane Library and Embase. 12 clinical randomised controlled trials with 3402 patients with AIS met the inclusion criteria. The primary, secondary and tertiary outcomes were modified Rankin Scale (mRS) scores 0–1, mortality at 90th day after treatment and symptomatic intracerebral haemorrhage within 36 hours, respectively. Network meta-analysis and conventional meta-analysis were carried out for calculating odds ratio (OR), the surface under cumulative ranking curve (SUCRA) and the probabilities of being the best.ResultsFor mRS, alteplase regardless of time delay was significantly more effective than placebo (OR 1.33–2.17). However, alteplase used within 3 hours after AIS occurrence (SUCRA=98.3%) was significantly more effective (OR=1.64) than that at 3–4.5 hours (SUCRA=43%) and showed the trend of priority (OR=1.47) compared with that beyond 4.5 hours (SUCRA=58%). For the mortality, compared with placebo (SUCRA=64.7%), alteplase within 3 hours was similar to that of 3–4.5 hours whereas alteplase beyond 4.5 hours (SUCRA=7.3%) showed the trend of significantly increasing 85% mortality. For the tertiary outcome, alteplase within 3 hours (SUCRA=19.0%) was comparable with placebo (SUCRA=99.9%) whereas alteplase beyond 3 hours significantly increased (OR 5.89–6.67) the symptomatic intracerebral haemorrhage.ConclusionsAlteplase within 3 hours should be recommended as the best treatment delay for its best efficacy among all the intervention and equivalent safety compared with placebo. Alteplase beyond 3 hours was less effective compared with that within 3 hours and increased the risk of mortality on 3 months as well as symptomatic intracerebral haemorrhage at 36 hours. More head-to-head clinical trials are needed to confirm those findings.

scholarly journals Stent-based thrombectomy versus intravenous tissue plasminogen activator in acute ischaemic stroke: A systematic review and meta-analysis

2015 ◽  
Vol 21 (6) ◽  
pp. 684-690 ◽  
Author(s):  
Reuben Grech ◽  
Mark Schembri ◽  
John Thornton
Keyword(s):  
Systematic Review ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
High Rate ◽  
Significant Heterogeneity ◽  
Intravenous Tissue Plasminogen Activator ◽  
Randomised Controlled

Purpose To date only a few studies have compared the effectiveness and functional outcomes of stent retrievers versus intravenous thrombolysis in acute ischaemic stoke. Our aim was to identify and collate all the available data and to assess for statistical differences in patient outcomes between the two treatments. Materials and methods We performed a systematic review and meta-analysis of studies with a randomised controlled design which utilised stentrievers and intravenous thrombolysis in acute ischaemic stroke. Results Five randomised controlled studies published in 2015 were identified. Second-generation thrombectomy devices constituted at least 80% of thrombectomy devices in the included studies, namely MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and REVASCAT. No significant heterogeneity was seen in the included studies and the five trials were therefore included in the meta-analysis. A total of 46.10% of patients treated with stentrievers achieved an independent functional outcome (mRS < 2) at 90 days compared with 26.46% of those treated with intravenous thrombolysis with an odds ratio of 2.40 ( p < 0.001). The weighted recanalisation mean in the thrombectomy arms was 76.02%. A lower mortality rate was observed with stentrievers compared to intravenous thrombolysis (15.33% vs 18.74%; OR 0.81, p = 0.15). Stentrievers were also associated with a lower risk of symptomatic intracranial haemorrhage (7.86% vs 8.64%; OR 1.02, p = 0.93). The differences in the secondary/safety outcomes were not statistically significant. Conclusion Stentrievers can achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. Our meta-analysis demonstrates a clear benefit of an intra-arterial mechanical approach vs standard treatment.

scholarly journals Sedation versus general anaesthesia in endovascular therapy for anterior circulation acute ischaemic stroke: the multicentre randomised controlled AMETIS trial study protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (9) ◽  
pp. e027561 ◽  
Author(s):  
Russell Chabanne ◽  
Charlotte Fernandez-Canal ◽  
Vincent Degos ◽  
Anne-Claire Lukaszewicz ◽  
Lionel Velly ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Functional Outcome ◽  
General Anaesthesia ◽  
Endovascular Therapy ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Acute Pulmonary Oedema ◽  
Anterior Circulation ◽  
Randomised Controlled

IntroductionEndovascular thrombectomy is the standard of care for anterior circulation acute ischaemic stroke (AIS) secondary to emergent large vessel occlusion in patients who qualify. General anaesthesia (GA) or conscious sedation (CS) is usually required to ensure patient comfort and avoid agitation and movement during thrombectomy. However, the question of whether the use of GA or CS might influence functional outcome remains debated. Indeed, conflicting results exist between observational studies with better outcomes associated with CS and small monocentric randomised controlled trials favouring GA. Therefore, we aim to evaluate the effect of CS versus GA on functional outcome and periprocedural complications in endovascular mechanical thrombectomy for anterior circulation AIS.Methods and analysisAnesthesia Management in Endovascular Therapy for Ischemic Stroke (AMETIS) trial is an investigator initiated, multicentre, prospective, randomised controlled, two-arm trial. AMETIS trial will randomise 270 patients with anterior circulation AIS in a 1:1 ratio, stratified by centre, National Institutes of Health Stroke Scale (≤15 or >15) and association of intravenous thrombolysis or not to receive either CS or GA. The primary outcome is a composite of functional independence at 3 months and absence of perioperative complication occurring by day 7 after endovascular therapy for anterior circulation AIS. Functional independence is defined as a modified Rankin Scale score of 0–2 by day 90. Perioperative complications are defined as intervention-associated arterial perforation or dissection, pneumonia or myocardial infarction or cardiogenic acute pulmonary oedema or malignant stroke evolution occurring by day 7.Ethics and disseminationThe AMETIS trial was approved by an independent ethics committee. Study began in august 2017. Results will be published in an international peer-reviewed medical journal.Trial registration numberNCT03229148.

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