Endovascular Thrombectomy for Acute Ischemic Stroke
Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis
Jetan et al. JAMA 2015; 314(17): 1832-43
Endovascular intervention for acute ischemic stroke has been shown improve revascularization but with variable functional outcomes. Goal- to compare functional outcomes in patients with acute ischemic stroke who receive mechanical thrombectomy vs standard medical therapy
A meta-analysis of 8 RCTs including 2423 total patients. Systematic data review conducted through August 2015. Eligible studies were RCTs of adults (>18) with acute ischemic stroke managed with some endovascular treatment vs medical management, which could include intravenous tPA. Endovascular tx was defined as use of an intra-arterial catheter/device for thrombectomy +/-arterial thrombolytics. All studies commented on functional outcome using the modified Rankin scale (mRS). Time to endovascular intervention was <12 hours from sx onset with the majority of patients having mechanical thrombectomy in <6 hours.
-1313 patients in the endovascular group, 1110 in the standard tx group
-looked at functional outcomes using mRS between treatment groups and across multiple subgroups
thrombectomy was associated with a significant treatment benefit across mRS scores – essentially more patients in the thrombectomy group had lower mRS scores/less disability and improved outcomes at 90 days
The endovascular tx group was specifically associated with greater functional independence at 90 days and higher rates of angiographic revascularization at 24 hours with no significant difference in rate of symptomatic ICH or all-cause mortality at 90 days between groups. In subgroup analysis there was no significant difference in outcome based on age, gender or NIHSS. Outcomes were better among patients with angio confirming a proximal clot prior to endovascular intervention, patients who received peripheral tPA + endovascular intervention, and when newer stent retrieval devices were used for thrombectomy. Functional outcomes were generally better in more recent trials.
In patients with acute ischemic stroke endovascular tx with thrombectomy was associated with better functional outcomes when compared to standard medical tx/peripheral tPA alone, and no significant increase in ICH/mortality at 90 days. A combination of endovascular tx and peripheral tPA may yield better outcomes. Further studies needed to investigate use of specific endovascular devices, optimal treatment window and patient population.