Efficacy and Safety of Endovascular Treatment for Acute Large-Vessel Ischemic Stroke Beyond 6 h After Symptom Onset: A Meta-Analysis

Background: There is considerable evidence on the benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) within 6 h after symptom onset. However, uncertainties remain regarding EVT efficacy beyond 6 h after symptom onset. We undertook a meta-analysis to assess the efficacy and safety of EVT in patients with AIS >6 h after symptom onset.Methods: We searched PubMed, EMBASE, and Chinese Biomedical through July 2019. We included studies involving early (≤6 h) vs. delayed (>6 h) EVT in selected patients with AIS, based on radiological evaluation criteria. Functional independence, successful recanalization, mortality, and symptomatic intracranial hemorrhage (sICH) rates were assessed.Results: Eight articles, with 3,265 patients who had undergone early EVT and 1,078 patients who had received delayed EVT, were included in the meta-analysis. Patients treated with early EVT showed a similar proportion of functional independence at 90 days [odds ratio (OR) = 1.14, 95% confidence interval (CI) = 0.926–1.397, P = 0.219; I2 = 36.2%, P = 0.128] as those treated with delayed EVT. Delayed EVT was also associated with no significant difference in mortality (OR = 1.015, 95% CI = 0.852–1.209; P = 0.871; I2 = 0.0%, P = 0.527), successful recanalization (OR = 1.255, 95% CI = 0.923–1.705; P = 0.147; I2 = 60.5%, P = 0.009), and sICH (OR = 0.976, 95% CI = 0.737–1.293; P = 0.871; I2 = 0.0%, P = 0.742) rates compared with early EVT.Conclusions: Among selected patients with AIS, delayed EVT showed comparable outcomes in functional independence, recanalization, mortality, and sICH rates compared with early EVT.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017667 ◽

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.

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Comparative Analysis on Low- and Standard-Dose Regimes of Alteplase Thrombolytic Therapy for Acute Ischemic Stroke: Efficacy and Safety

European Neurology ◽

10.1159/000485460 ◽

2017 ◽

Vol 79 (1-2) ◽

pp. 68-73 ◽

Cited By ~ 2

Author(s):

Guangjian Zhao ◽

Tingfen Huang ◽

Mei Zheng ◽

Yansen Cui ◽

Yunyong Liu ◽

...

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Dose Group ◽

Low Dose ◽

Standard Dose ◽

Efficacy And Safety ◽

Significant Difference ◽

Symptomatic Intracranial Hemorrhage ◽

Intravenous Alteplase

Objective: This study analyzed the efficacy and safety of low-dose and standard-dose alteplase intravenous thrombolytic therapy for acute ischemic stroke (AIS). Methods: Patients with AIS who underwent intravenous alteplase thrombolysis from July 2012 to December 2016 were retrospectively analyzed and correspondingly divided into low-dose (0.6–0.89 mg/kg) group and standard-dose group (0.9 mg/kg) according to alteplase dosage. The clinical outcome was evaluated by modified Rankin Scale (mRS) at 90 days after onset. The safety index was the mortality at 90 days after onset and the incidence of symptomatic intracranial hemorrhage (SICH) within 7 days. Results: A total of 1,486 patients were included (1,115 cases in low-dose group and 371 cases in standard-dose group). There were no significant differences in baseline data between the 2 groups. As mRS, good outcome rate as well as mortality rate in both groups had no significant difference (36.1 vs. 37.6%; χ2 = 10.882, p = 0.890; 5.5 vs. 7.3%; χ2 = 2.163, p = 0.076), but the incidence of SICH in low-dose group was significantly lower than that of the standard-dose group (2.2 vs. 5.9%; χ2 = 3.157, p = 0.001). Conclusion: The efficacy of low-dose alteplase intravenous thrombolytic therapy for AIS was equivalent to the standard-dose regimen but with higher safety.

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Abstract T P48: Intravenous Thrombolysis Using Low-Dose Alteplase for Nonagenarians with Acute Ischemic Stroke: The SAMURAI rtPA Registry

Stroke ◽

10.1161/str.45.suppl_1.tp48 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mikito Hayakawa ◽

Masatoshi Koga ◽

Shoichiro Sato ◽

Shoji Arihiro ◽

Yoshiaki Shiokawa ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Low Dose ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Efficacy And Safety ◽

Multivariate Adjustment ◽

Potential Efficacy ◽

Symptomatic Intracranial Hemorrhage ◽

Baseline Characteristics

Objective: Although intravenous thrombolysis (IVT) using alteplase for octogenarians with acute ischemic stroke becomes relatively familiar, it is unclear whether IVT for nonagenarians is a futile intervention. The purpose of this study is to clarify the efficacy and safety of IVT using low-dose alteplase (0.6 mg/kg) for nonagenarians compared with octogenarians. Methods: Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI) rtPA registry retrospectively collected 600 consecutive acute stroke patients receiving IVT from 10 Japanese stroke centers between October 2005 and July 2008. We extracted all octogenarians (O group) and nonagenarians (N group) from the registry. We compared baseline characteristics, symptomatic intracranial hemorrhage (SICH), and 3-month outcomes between the groups. 3-month outcomes include; functional independence (FI) defined as a mRS score 0-2, good outcome (GO) as a mRS score 0-2 or same as the premorbid mRS, poor outcome (PO) defined as a mRS score 5-6, and death. Results: Twenty-five nonagenarians (mean age, 93 years) and 124 octogenarians (mean age, 84 years) were included. N group was more female-predominant (76% versus 56%, p=0.06) and premorbidly dependent (44% versus 14%, p<0.001) than O group. There were no significant differences of median baseline NIHSS score (16 versus 14, p=0.95) and Alberta Stroke Program Early CT Score (9 versus 9, p=0.36) between the groups. The rate of FI tended to be lower in N group than O group (16% versus 36%, p=0.06), otherwise, the differences of the rates of GO (28% versus 37%, p=0.39), PO (40% versus 36%, p=0.73), death (20% versus 11%, p=0.23) and SICH (0% versus 2.4%, p=1.00) were not significant between the groups. In comparison with O group, N group was not associated with 3-month clinical outcomes (FI; OR 0.61; 95% CI, 0.15-2.42, GO; 0.98; 0.31-3.07, PO; 0.63; 0.15-2.70, death; 3.18; 0.62-16.3) and SICH (0.68; 0.17-2.69) after multivariate adjustment. Conclusions: IVT using low-dose alteplase for N group resulted in less frequent achievement of FI mainly because of more premorbid dependency than O group, however, showed at least a similar safety and a potential efficacy.

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

International Journal of Stroke ◽

10.1177/17474930211047337 ◽

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), 0.39â0.62) and higher mortality (OR, 2.55; 95% CI, 2.03â3.21). RI was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63â1.00) and sICH (OR, 1.41; 95% CI, 0.95â2.10). 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, 0.45â0.77), mortality (OR, 2.23, 95% CI, 1.45â3.43), and sICH (OR, 1.34; 95% CI, 0.85â2.10). 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

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Abstract WP112: Thrombolysis for AIS in the Unwitnessed or Extended Therapeutic Time Window: A Systematic Review and Meta-Analysis

Stroke ◽

10.1161/str.51.suppl_1.wp112 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Aristeidis H Katsanos ◽

Konark Malhotra ◽

Amrou Sarraj ◽

Andrew Barreto ◽

Martin Köhrmann ◽

...

Keyword(s):

Symptom Onset ◽

Time Window ◽

Meta Analysis ◽

Onset Time ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Functional Improvement ◽

Increased Risk ◽

Significant Difference ◽

All Cause Mortality

Introduction: We sought to assess the utility of intravenous thrombolysis (IVT) treatment in acute ischemic stroke (AIS) patients with unclear symptom onset time or outside the 4.5 hour time window, selected by advanced neuroimaging. Methods: We performed random-effects meta-analyses on the unadjusted and adjusted for potential confounders associations of IVT (alteplase 0.9 mg/kg) with the following outcomes: 3-month favorable functional outcome [FFO, modified Rankin Scale (mRS) scores: 0-1], 3-month functional independence (FI, mRS-scores: 0-2), 3-month mortality, 3-month functional improvement (assessed with ordinal analysis on the mRS-scores), symptomatic intracranial hemorrhage (sICH) and complete recanalization (CR). Results: We identified 4 eligible RCTs (859 total patients). In unadjusted analyses IVT was associated with higher likelihood of 3-month FFO (OR=1.48, 95%CI:1.12-1.96), FI (OR=1.42, 95%CI:1.07-1.90), sICH (OR=5.28, 95%CI:1.35-20.68) and CR (OR=3.29, 95%CI:1.90-5.69), with no significant difference in the odds of all-cause mortality risk at three months (OR=1.75, 95%CI: 0.93-3.29). In the adjusted analyses IVT was also associated with higher odds of 3-month FFO (OR adj =1.62, 95%CI:1.20-2.20), functional improvement (OR adj =1.42, 95%CI: 1.11-1.81) and sICH (OR adj =6.22, 95%CI: 1.37-28.26). There was no association between IVT and FI (OR adj =1.61, 95%CI: 0.94-2.75) or all-cause mortality at three months (OR adj =1.75, 95%CI: 0.93-3.29). No evidence of heterogeneity was evident in any of the analyses (I 2 =0). Conclusion: IVT in AIS patients with unknown symptom onset time or elapsed time from symptom onset more than 4.5 hours, selected with advanced neuroimaging, results in a higher likelihood of complete recanalization and functional improvement at three months despite the increased risk of sICH.

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Outcomes between in-hospital stroke and community-onset stroke after thrombectomy: Propensity-score matching analysis

Interventional Neuroradiology ◽

10.1177/15910199211030769 ◽

2021 ◽

pp. 159101992110307

Author(s):

Kai Qiu ◽

Qing-Quan Zu ◽

Lin-Bo Zhao ◽

Sheng Liu ◽

Hai-Bin Shi

Keyword(s):

Ischemic Stroke ◽

Propensity Score ◽

Acute Ischemic Stroke ◽

Propensity Score Matching ◽

Symptom Onset ◽

Endovascular Thrombectomy ◽

Number Of Patients ◽

Significant Difference ◽

Stroke Group ◽

Community Onset

Background The benefit of endovascular thrombectomy for patients with in-hospital stroke remains unclear. Thus, the aim of this study was to compare the endovascular thrombectomy outcomes between in-hospital stroke and community-onset stroke among patients with acute ischemic stroke. Methods From January 2015 to July 2019, 362 consecutive patients with acute ischemic stroke with large vessel occlusion in the anterior circulation received endovascular thrombectomy in our centre. After propensity score matching with a ratio of 1:2 (in-hospital stroke:community-onset stroke), clinical characteristics and functional outcomes were compared between in-hospital stroke and community-onset stroke groups. Results Thirty-six patients with in-hospital stroke and 72 patients with community-onset stroke were enrolled. The number of patients with New York Heart Association classification III/IV (41.7% vs. 6.9%, p < 0.001) and with underlying cancer (25.0% vs. 2.8%, p < 0.001) was higher in the in-hospital stroke than in the community-onset stroke group. The intravenous thrombolysis rate was lower in the in-hospital stroke group (13.9% vs. 43.1%, p = 0.002). No significant difference in symptom onset to puncture ( p = 0.618), symptom onset to recanalisation ( p = 0.618) or good reperfusion (modified thrombolysis in cerebral infarction ≥2 b) rates ( p = 0.852) was found between the groups. The favourable clinical outcome trend (modified Rankin scale ≤2 at 90 days) was inferior, but acceptable, in the in-hospital stroke, group compared to the community-onset stroke group (30.6% vs. 41.7%, p = 0.262). Conclusion Patients with in-hospital stroke had more disadvantageous comorbidities than those with community-onset stroke. Cardiac dysfunction seems to be associated with poor outcomes after thrombectomy. Nevertheless, endovascular thrombectomy still appears to be safe and effective for patients with in-hospital stroke.

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Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015147 ◽

2019 ◽

Vol 12 (3) ◽

pp. 266-270 ◽

Cited By ~ 7

Author(s):

Eric S Sussman ◽

Blake Martin ◽

Michael Mlynash ◽

Michael P Marks ◽

David Marcellus ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Independence ◽

Inclusion Criteria ◽

Related Factors ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Improved Outcomes ◽

Symptomatic Intracranial Hemorrhage ◽

The Difference

IntroductionMultiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.MethodsWe performed a retrospective cohort study at a single center. Inclusion criteria were: age 80–99, LVO, core infarct <70 mL, and salvageable penumbra. Patients were stratified into octogenarian (80–89) and nonagenarian (90–99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ≤2 vs mRS ≥3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.Results108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b–3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ≤2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.ConclusionsNonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

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Endovascular thrombectomy for the treatment of ischemic stroke: An updated meta-analysis for a randomized controlled trial

Journal of Neurorestoratology ◽

10.26599/jnr.2021.9040014 ◽

2021 ◽

Vol 9 (3) ◽

pp. 166-176

Author(s):

Jia Feng ◽

Zhihan Zhu ◽

Ahmed Waqas ◽

Lukui Chen

Keyword(s):

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Functional Outcome ◽

Meta Analysis ◽

Intervention Group ◽

Intravenous Thrombolysis ◽

Control Group ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference

Objective:To evaluate whether endovascular thrombectomy combined with intravenous thrombolysis is superior to the standard treatment of intravenous thrombolysis for the treatment of ischemic stroke.Methods:A meta-analysis of 12 studies obtained by searching PubMed and Web of Science database was performed to determine whether the difference in mortality (within 7 days or 90 days), functional outcome (modified Rankin Scale, 0-2), hemorrhage (symptomatic intracerebral hemorrhage, and subarachnoid hemorrhage), and recurrent ischemic stroke rate at 90 days between patients who underwent mechanical intravenous thrombolysis with (intervention) and without (control) endovascular thrombectomy.Results:As compared with the control group, patients in the intervention group had lower 90-day mortality [summary risk ratio (RR) = 0.83, 95% confidence interval (CI): 0.69-0.99; n = 1309/1070], higher recanalization rate (RR = 2.24, 95% CI: 1.97-2.56; n = 504/497), better functional outcome (modified Rankin score: 0-2; RR = 1.41, 95% CI: 1.29-1.54; n = 1702/1502), and higher rate of subarachnoid hemorrhage (RR = 2.40, 95% CI: 1.45-3.99; n = 1046/875) without significant difference in the 7-day mortality (RR = 1.12, 95% CI: 0.84-1.50; n = 951/773), symptomatic intracranial hemorrhage (RR = 1.12, 95% CI: 0.82-1.54; n = 1707/1507), or recurrent ischemic stroke (RR = 0.90, 95% CI: 0.52-1.54; n = 718/506).Conclusion:Our results demonstrated that patients in the intervention group had lower mortality and better functional outcomes than the control group. Although patients in the intervention group had a higher rate of subarachnoid hemorrhage; hence, endovascular thrombectomy combined with intravenous thrombolysis is still a beneficial intervention for a defined population of stroke patients.

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Abstract WP103: Re-Examining the Exclusion Criterion of Early Recurrent Ischemic Stroke in Intravenous Thrombolysis: A Meta-Analysis

Stroke ◽

10.1161/str.51.suppl_1.wp103 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Katrina Hannah Ignacio ◽

Jose Danilo Diestro ◽

Adrian Espiritu ◽

Julian Spears ◽

Maria Cristina San Jose

Keyword(s):

Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Functional Outcomes ◽

Recurrent Stroke ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Exclusion Criterion ◽

Intravenous Tissue Plasminogen Activator ◽

Significant Difference ◽

Symptomatic Intracranial Hemorrhage

Background: Current guidelines for intravenous tissue plasminogen activator for acute ischemic stroke preclude the administration of the drug in patients with a history of recent stroke. Objectives: Our meta-analysis aims to determine the safety and efficacy of thrombolysis in patients with early recurrent ischemic stroke (within 3 months of initial stroke). Methods: Pubmed, Cochrane, Scopus, Embase, Clinicaltrials.gov , and HERDIN were searched for studies comparing the outcomes of acute stroke patients undergoing intravenous thrombolysis between those with early recurrent stroke (ERS) and those without. Random-effects meta-analysis was used to evaluate the outcomes in terms of symptomatic intracranial hemorrhage, mortality and good functional outcomes at 3 months (modified Rankin Score < 2 ) Results: Three observational studies with a total of 48,459 thrombolysed patients (824 with ERS and 47,635 without) were included in the study. There was no significant difference between patients with ERS and those without in terms of symptomatic intracranial hemorrhage (OR 1.39, 95% Confidence Interval [CI] 0.75-2.58), mortality (OR 1.36, 95% CI 0.60-3.09) and good functional outcomes at 3 months (OR 0.74, 95% CI 0.47-1.16). Conclusion: Our meta-analysis suggests that there is insufficient evidence to substantiate excluding patients with ERS from receiving thrombolysis. Further studies to re-examine ERS as an exclusion criterion for receiving thrombolysis are warranted.

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121 Endovascular Thrombectomy Alone versus Combined Intravenous Thrombolysis and Thrombectomy: A Systematic Review and Meta-Analysis

Neurosurgery ◽

10.1093/neuros/nyx417.121 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 226-227

Author(s):

Kevin Phan ◽

Adam Dmytriw ◽

Christoph Johannes Griessenauer ◽

Justin M Moore ◽

Christopher S Ogilvy ◽

...

Keyword(s):

Fixed Effects ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Endovascular Thrombectomy ◽

Safety Outcome ◽

Relative Risks ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference ◽

Symptomatic Intracranial Hemorrhage ◽

Iv Tpa

Abstract INTRODUCTION To date, no randomized trial has directly addressed the question of whether IV tPA improves the outcomes of IV tPA-eligible patients who will eventually undergo EVT or whether a direct EVT strategy will be equally effective. METHODS We performed a search on 6 electronic databases publications up until January 2017. All prospective and retrospective articles on comparing the efficacy and safety between mechanical thrombectomy (MT) alone and combined thrombectomy with IV tPA (MT + IVT) were included. The modified Rankin scale score between 0–2 at 90 days was used to analysed the primary efficacy whereby the primary safety outcome was all-cause mortality at 90 days. Summary relative risks and 95% confidence intervals calculated with a fixed-effects or random-effects model where appropriate. RESULTS >12 studies were included for analysis, comprising 1275 in the EVT only arm and 1340 in the combined EVT+IV tPA arm. Good functional outcomes (mRS = 2) was not statistically significant when comparing EVT versus EVT+IV tPA (44% vs 48%, OR 0.80, 95% CI 0.64, 1.002, P = 0.052). Similar findings was found in the primary safety outcome, 90-day mortality rates (20.4% vs 19.4%, OR 1.19, 95% CI 0.83, 1.71, P = 0.34). Symptomatic intracranial hemorrhage was also not significantly different between EVT versus EVT+IV tPA (3.7% vs 3.8%, OR 0.98, 95% CI 0.65-1.48, P = 0.91). CONCLUSION Overall, no significant difference was found between the groups in terms of favorable functional outcome, mortality rate or complications including symptomatic intracerebral hemorrhage. Our results suggest that a subset of acute ischemic stroke patients may benefit from a direct EVT alone approach.

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