Endovascular Thrombectomy as a Means to Improve Survival in Acute Ischemic Stroke: A Meta-analysis

Yingfeng Lin; Volker Schulze; Maximilian Brockmeyer; Claudio Parco; Athanasios Karathanos; Yvonne Heinen; Michael Gliem; Hans-Peter Hartung; Gerald Antoch; Sebastian Jander; Bernd Turowski; Stefan Perings; Malte Kelm; Georg Wolff

doi:10.1001/jamaneurol.2019.0525

Bracard 听S, Ducrocq 听X, Mas 听JL, 听et al; THRACE Investigators. 听Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial.听听尝补苍肠别迟 Neurol. 2016;15(11):1138-1147. doi:

Campbell 听BC, Mitchell 听PJ, Kleinig 听TJ, 听et al; EXTEND-IA Investigators. 听Endovascular therapy for ischemic stroke with perfusion-imaging selection.听听N Engl J Med. 2015;372(11):1009-1018. doi:

Saver 听JL, Goyal 听M, Bonafe 听A, 听et al; SWIFT PRIME Investigators. 听Stent-retriever thrombectomy after intravenous t-PA vs t-PA alone in stroke.听听N Engl J Med. 2015;372(24):2285-2295. doi:

Jovin 听TG, Chamorro 听A, Cobo 听E, 听et al; REVASCAT Trial Investigators. 听Thrombectomy within 8 hours after symptom onset in ischemic stroke.听听N Engl J Med. 2015;372(24):2296-2306. doi:

Mocco 听J, Zaidat 听OO, von Kummer 听R, 听et al; THERAPY Trial Investigators. 听Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone.听听厂迟谤辞办别. 2016;47(9):2331-2338. doi:

Berkhemer 听OA, Fransen 听PS, Beumer 听D, 听et al; MR CLEAN Investigators. 听A randomized trial of intraarterial treatment for acute ischemic stroke.听听N Engl J Med. 2015;372(1):11-20. doi:

Powers 听WJ, Rabinstein 听AA, Ackerson 听T, 听et al; American Heart Association Stroke Council. 听2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.听听厂迟谤辞办别. 2018;49(3):e46-e110. doi:

Ibanez 听B, James 听S, Agewall 听S, 听et al; ESC Scientific Document Group. 听2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation of the European Society of Cardiology (ESC).听听Eur Heart J. 2018;39(2):119-177. doi:

Nogueira 听RG, Jadhav 听AP, Haussen 听DC, 听et al; DAWN Trial Investigators. 听Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.听听N Engl J Med. 2018;378(1):11-21. doi:

10.

Albers 听GW, Marks 听MP, Kemp 听S, 听et al; DEFUSE 3 Investigators. 听Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.听听N Engl J Med. 2018;378(8):708-718. doi:

11.

Goyal 听M, Demchuk 听AM, Menon 听BK, 听et al; ESCAPE Trial Investigators. 听Randomized assessment of rapid endovascular treatment of ischemic stroke.听听N Engl J Med. 2015;372(11):1019-1030. doi:

12.

Kidwell 听CS, Jahan 听R, Gornbein 听J, 听et al; MR RESCUE Investigators. 听A trial of imaging selection and endovascular treatment for ischemic stroke.听听N Engl J Med. 2013;368(10):914-923. doi:

13.

Goyal 听M, Menon 听BK, van Zwam 听WH, 听et al; HERMES Collaborators. 听Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.听听尝补苍肠别迟. 2016;387(10029):1723-1731. doi:

14.

Rom谩n 听LS, Menon 听BK, Blasco 听J, 听et al; HERMES Collaborators. 听Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data.听听尝补苍肠别迟 Neurol. 2018;17(10):895-904. doi:

15.

van den Berg 听LA, Dijkgraaf 听MG, Berkhemer 听OA, 听et al; MR CLEAN Investigators. 听Two-year outcome after endovascular treatment for acute ischemic stroke.听听N Engl J Med. 2017;376(14):1341-1349. doi:

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Key Points

Question听 Is there a benefit for short-term survival with endovascular thrombectomy vs medical therapy in acute ischemic stroke?

Findings听 In this meta-analysis of all randomized clinical trials of endovascular thrombectomy vs medical therapy cited in the 2018 American Stroke Association/American Heart Association guidelines for acute ischemic stroke, endovascular thrombectomy significantly reduced the risk for 90-day mortality compared with medical therapy, without a difference in risk of intracranial hemorrhage.

Meaning听 There is considerable evidence of the benefits of endovascular thrombectomy for survival during the first 90 days after acute ischemic stroke.

Abstract

Importance听 Although endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality.

Objective听 To identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis.

Data Sources听 All randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines.

Study Selection听 Ten American Stroke Association/American Heart Association guideline鈥搑elevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT.

Data Extraction and Synthesis听 Data were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs.

Main Outcomes and Measures听 Risk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward).

Results听 In 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98; P鈥�=鈥�.03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01; P鈥�=鈥�.06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40; P鈥�=鈥�.38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72; P鈥�=鈥�.65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials.

Conclusions and Relevance听 This meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.

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