Journal Article

Endovascular Treatment with Stent-Retriever Devices for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Li, Changwei, Kelly, Tanika, Conner, Katherine R., Martin-Schild, Sheryl, Kurimella, Dayaamayi, Cross, Lee J. S., He, Jiang, Bush, Chad K., Chen, Jing

2016

Overview

Acute ischemic stroke is a leading cause of death and disability worldwide. Several recent clinical trials have shown that endovascular treatment improves clinical outcomes among patients with acute ischemic stroke. To provide an overall and precise estimate of the efficacy of endovascular treatment predominantly using second-generation mechanical thrombectomy devices (stent-retriever devices) compared to medical management on clinical and functional outcomes among patients with acute ischemic stroke. MEDLINE, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, Web of Science, and NIH ClinicalTrials.gov were searched through November 2015. Searches returned 3,045 articles. After removal of duplicates, two authors independently screened titles and abstracts to assess eligibility of 2,495 potentially relevant publications. From these, 38 full-text publications were more closely assessed. Finally, 5 randomized controlled trials of endovascular treatment with predominant use of retrievable stents were selected. Three authors independently extracted information on participant and trial characteristics and clinical events using a standardized protocol. Random effects models were used to pool endovascular treatment effects across outcomes. The primary outcome was better functional outcome as measured on the modified Rankin Scale at 90 days of follow-up. Secondary outcomes included all-cause mortality and symptomatic intra-cerebral hemorrhage. Five trials representing 1,287 patients were included. Overall, patients randomized to endovascular therapy experienced 2.22 times greater odds of better functional outcome compared to those randomized to medical management (95% CI, 1.66 to 2.98; P < 0.0001). Endovascular therapy was not associated with mortality [OR (95% CI), 0.78 (0.54, 1.12); P = 0.1056] or symptomatic intracerebral hemorrhage [OR (95% CI), 1.19 (0.69, 2.05); P = 0.5348]. Meta-regression analysis suggested that shorter times from stroke onset to groin puncture and from stroke onset to reperfusion result in better functional outcomes in ischemic stroke patients (P = 0.0077 and P = 0.0089). There were no significant differences in the beneficial effects of endovascular treatment on functional outcomes across categories of gender, age, stroke severity, ischemic changes on computed tomography, or intravenous tissue plasminogen activator administration. This meta-analysis demonstrated superior functional outcomes in subjects receiving endovascular treatment compared to medical management. Further, this analysis showed that acute ischemic stroke patients may receive enhanced functional benefit from earlier endovascular treatment.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Acute Disease / Bias / Biology and Life Sciences / Brain Damage, Chronic - etiology / Brain Damage, Chronic - prevention & control / Brain Ischemia - surgery / Cardiovascular system / Cerebral Hemorrhage - etiology / Clinical trials / Combined Modality Therapy / Computed tomography / Documents / Endovascular Procedures - adverse effects / Endovascular Procedures - instrumentation / Endovascular Procedures - statistics & numerical data / Epidemiology / Fibrinolytic Agents - adverse effects / Fibrinolytic Agents - therapeutic use / Hemorrhage / Humans / Implants / Intravenous administration / Ischemia / Management / Mechanical Thrombolysis - adverse effects / Mechanical Thrombolysis - instrumentation / Mechanical Thrombolysis - statistics & numerical data / Medical electronics / Medical research / Medicine / Medicine and Health Sciences / Meta-analysis / Mortality / Multicenter Studies as Topic - statistics & numerical data / Patients / Physical Sciences / Postoperative Complications - etiology / Postoperative Complications - prevention & control / Prospective Studies / Public health / Randomization / Randomized Controlled Trials as Topic - statistics & numerical data / Regression analysis / Reperfusion / Reperfusion Injury - etiology / Reperfusion Injury - prevention & control / Research and Analysis Methods / Stents / Stroke / Studies / Surgical implants / Systematic review / t-Plasminogen activator / Therapy / Thrombectomy - adverse effects / Thrombectomy - instrumentation / Thrombectomy - statistics & numerical data / Thrombolytic Therapy - adverse effects / Time Factors / Tissue Plasminogen Activator - adverse effects / Tissue Plasminogen Activator - therapeutic use / Treatment Outcome