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

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.

scholarly journals Mechanical Thrombectomy in Acute Ischemic Stroke: A Systematic Review

2016 ◽  
Vol 43 (4) ◽  
pp. 455-460 ◽  
Author(s):  
Anna Lambrinos ◽  
Alexis K. Schaink ◽  
Irfan Dhalla ◽  
Timo Krings ◽  
Leanne K. Casaubon ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Clinical Effectiveness ◽  
Functional Independence ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Best Medical Therapy

AbstractAlthough intravenous thrombolysis increases the probability of a good functional outcome in carefully selected patients with acute ischemic stroke, a substantial proportion of patients who receive thrombolysis do not have a good outcome. Several recent trials of mechanical thrombectomy appear to indicate that this treatment may be superior to thrombolysis. We therefore conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of new-generation mechanical thrombectomy devices with intravenous thrombolysis (if eligible) compared with intravenous thrombolysis (if eligible) in patients with acute ischemic stroke caused by a proximal intracranial occlusion. We systematically searched seven databases for randomized controlled trials published between January 2005 and March 2015 comparing stent retrievers or thromboaspiration devices with best medical therapy (with or without intravenous thrombolysis) in adults with acute ischemic stroke. We assessed risk of bias and overall quality of the included trials. We combined the data using a fixed or random effects meta-analysis, where appropriate. We identified 1579 studies; of these, we evaluated 122 full-text papers and included five randomized control trials (n=1287). Compared with patients treated medically, patients who received mechanical thrombectomy were more likely to be functionally independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39; 95% confidence interval, 1.88-3.04; I2=0%). This finding was robust to subgroup analysis. Mortality and symptomatic intracerebral hemorrhage were not significantly different between the two groups. Mechanical thrombectomy significantly improves functional independence in appropriately selected patients with acute ischemic stroke.

scholarly journals The Impact of Post-contrast Acute Kidney Injury on In-hospital Mortality After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Mona Laible ◽  
Ekkehart Jenetzky ◽  
Markus Alfred Möhlenbruch ◽  
Martin Bendszus ◽  
Peter Arthur Ringleb ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Kidney Injury ◽  
Stroke Severity ◽  
Post Contrast ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage ◽  
The Impact

Background and Purpose: Clinical outcome and mortality after endovascular thrombectomy (EVT) in patients with ischemic stroke are commonly assessed after 3 months. In patients with acute kidney injury (AKI), unfavorable results for 3-month mortality have been reported. However, data on the in-hospital mortality after EVT in this population are sparse. In the present study, we assessed whether AKI impacts in-hospital and 3-month mortality in patients undergoing EVT.Materials and Methods: From a prospectively recruiting database, consecutive acute ischemic stroke patients receiving EVT between 2010 and 2018 due to acute large vessel occlusion were included. Post-contrast AKI (PC-AKI) was defined as an increase of baseline creatinine of ≥0.5 mg/dL or &gt;25% within 48 h after the first measurement at admission. Adjusting for potential confounders, associations between PC-AKI and mortality after stroke were tested in univariate and multivariate logistic regression models.Results: One thousand one hundred sixty-nine patients were included; 166 of them (14.2%) died during the acute hospital stay. Criteria for PC-AKI were met by 29 patients (2.5%). Presence of PC-AKI was associated with a significantly higher risk of in-hospital mortality in multivariate analysis [odds ratio (OR) = 2.87, 95% confidence interval (CI) = 1.16–7.13, p = 0.023]. Furthermore, factors associated with in-hospital mortality encompassed higher age (OR = 1.03, 95% CI = 1.01–1.04, p = 0.002), stroke severity (OR = 1.05, 95% CI = 1.03–1.08, p &lt; 0.001), symptomatic intracerebral hemorrhage (OR = 3.20, 95% CI = 1.69–6.04, p &lt; 0.001), posterior circulation stroke (OR = 2.85, 95% CI = 1.72–4.71, p &lt; 0.001), and failed recanalization (OR = 2.00, 95% CI = 1.35–3.00, p = 0.001).Conclusion: PC-AKI is rare after EVT but represents an important risk factor for in-hospital mortality and for mortality within 3 months after hospital discharge. Preventing PC-AKI after EVT may represent an important and potentially lifesaving effort in future daily clinical practice.

scholarly journals Thrombolysis Outcomes in Patients with Diabetes and Previous Stroke: A Meta-Analysis

2020 ◽  
Vol 47 (4) ◽  
pp. 486-493
Author(s):  
Azalea T. Pajo ◽  
Jose Danilo B. Diestro ◽  
Adrian I. Espiritu ◽  
Adam A. Dmytriw ◽  
Alejandro Enriquez-Marulanda ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Functional Independence ◽  
Tissue Type ◽  
Diabetic Patients ◽  
Eligibility Criteria ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Patients With Diabetes ◽  
Newcastle Ottawa Scale

ABSTRACT:Background:Intravenous tissue-type plasminogen activator (IVtPA) is a proven treatment for acute ischemic stroke; however, diabetes mellitus (DM) and previous cerebral infarction (PCI) were considered relative contraindications for thrombolysis within the 3–4.5 h period.Objective:The study aimed to determine the safety and efficacy of IVtPA among diabetic patients with PCI presenting with acute ischemic stroke.Methods:Studies which evaluated the outcome of IVtPA in terms of symptomatic intracerebral hemorrhage (sICH), functional outcome in modified Rankin scale, and death among diabetic patients with PCI presenting with acute ischemic stroke within the 3–4.5 h period were systematically searched until July 2019. Screening and eligibility criteria were applied. Risk of bias was evaluated using the Newcastle–Ottawa Scale. Odds ratios (ORs) with 95% confidence interval (CI) were used to compare measures of treatment effect. Mantel–Haenszel method and random-effects model were also employed.Results:Four registry-based studies with a total of 44,572 patients were included for quantitative synthesis. Giving IVtPA among DM+/PCI+ patients did not result in significantly increased rate of sICH (OR, 1.09; 95% CI, 0.88, 1.36) compared to No DM+/PCI+ patients. However, there was significantly higher mortality (OR, 1.81; 95% CI, 1.60, 2.06) in the DM+/PCI+ group. Conversely, among those who survived, the DM+/PCI+ patients were more functionally independent at 3 months (OR, 0.76; 95% CI, 0.61, 0.94).Conclusion:Limited evidence suggests that thrombolysis in DM+/PCI+ patients does not result in significantly higher incidence of sICH and may improve functional independence. However, the significantly higher mortality in this group warrants an assessment of the individualized risk–benefit ratio in the use of IVtPA.

scholarly journals Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results.

2019 ◽  
Author(s):  
Massimo Gamba ◽  
Nicola Gilberti ◽  
Enrico Premi ◽  
Angelo Costa ◽  
Michele Frigerio ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Safety Profile ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage

Abstract Background and Purpose endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients is still unclear. The present study aims to test whether IVT plus ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS by LVO. Methods we performed a single center retrospective observational study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. The patients were divided in 2 groups based on the treatment they received: CoT and, if IVT contraindicated, direct ET. We compared functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up infarct volume (EFIV) (for recanalized patients only) as well as safety profile, defined as symptomatic intracerebral hemorrhage (sICH) and 3-month mortality, between groups. Results 145 subjects were included in the study, 70 in direct ET group and 75 in CoT group. Patients who received CoT presented more frequently a functional independence at 3-months follow-up compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P<0.001. mRS score 0-2: 67.1% vs 37.3%; P<0.001), higher first-pass success rate (62.7% vs 38.6%, P<0.05), higher recanalization rate (84.3% vs 65.3%; P=0.009) and, in recanalized subjects, smaller EFIV (16.4ml vs 62.3ml; P=0.003). The safety profile was similar for the 2 groups. In multivariable regression analysis, low baseline NIHSS score (P<0.05), vessel recanalization (P=0.05) and CoT (P=0.03) were indipendent predictors of 3-month favorable outcome. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

C-reactive Protein, Infection, and Outcome After Acute Ischemic Stroke: A Registry and Systematic Review

2020 ◽  
Vol 16 (5) ◽  
pp. 405-415 ◽  
Author(s):  
Lu Wang ◽  
Yuxiao Li ◽  
Changyi Wang ◽  
Wen Guo ◽  
Ming Liu
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Reactive Protein ◽  
Poor Outcome ◽  
Pubmed Database ◽  
Scale Scores ◽  
The Impact

Background: A number of studies have explored the prognostic role of CRP in patients with acute ischemic stroke, however, the results have been inconclusive. The aim of our study was to investigate the impact of infection on the association between CRP and 3-month functional outcome by performing a registry study and systematic review. Methods: Patients admitted within 24 hours of acute ischemic stroke onset and had CRP measured within 24 hours after admission were included. Patients admitted between June 2016 and December 2018 in Chengdu Stoke Registry were enrolled. The PubMed database was searched up to July 2019 to identify eligible studies. Poor outcome was defined as modified Rankin Scale scores at 3-month more than 3. Results: Totally, 368 patients in the registry and 18 studies involving 15238 patients in the systematic review were included. A statistically significant association between CRP values on admission and 3-month poor outcome in patients without infection was found, both in our registry (CRP per 1-mg/L increment, OR 1.04, 95% CI 1.01 to 1.07, p=0.008) and meta-analysis (CRP per 1-mg/dL increment, OR 1.66 [95% CI 1.37 to 2.01, p<0.001]). In patients with infection, CRP was not associated with a 3-month poor outcome according to registry data (OR 1.00, 95% CI 0.99 to 1.01, p=0.663) and meta-analysis (OR 1.01, 95% CI 0.99 to 1.01, p=0.128). Conclusion: High CRP value was independently associated with a 3-month poor outcome after stroke in patients without infection. Further studies are required to examine the value of infection on CRP measures and long-term functional outcomes.

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.

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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