Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis.

2018-10-05

Phan, Kevin

Dmytriw, Adam A

Lloyd, Declan

Maingard, Julian M

Kok, Hong Kuan

Chandra, Ronil V

Brooks, Duncan Mark

Thijs, Vincent N

Moore, Justin M

Chiu, Albert Ho Yuen

Selim, Magdy

Goyal, Mayank

Pereira, Vitor Mendes

Thomas, Ajith J

Hirsch, Joshua A

Asadi, Hamed

Wang, Nelson

Stroke

thrombectomy

thrombolysis

Journal Article

0000-0002-6614-8417

0000-0003-0131-5699

0000-0001-8958-2411

0000-0003-2475-9727

0000-0002-1108-4225

10.1136/neurintsurg-2018-014260

The present Bayesian network meta-analysis aimed to compare the various strategies for acute ischemic stroke: direct endovascular thrombectomy within the thrombolysis window in patients with no contraindications to thrombolysis (DEVT); (2) direct endovascular thrombectomy secondary to contraindications to thrombolysis (DEVTc); (3) endovascular thrombectomy in addition to thrombolysis (IVEVT); and (4) thrombolysis without thrombectomy (IVT). Six electronic databases were searched from their dates of inception to May 2017 to identify randomized controlled trials (RCTs) comparing IVT versus IVEVT, and prospective registry studies comparing IVEVT versus DEVT or IVEVT versus DEVTc. Network meta-analyses were performed using ORs and 95% CIs as the summary statistic. We identified 12 studies (5 RCTs, 7 prospective cohort) with a total of 3161 patients for analysis. There was no significant difference in good functional outcome at 90 days (modified Rankin Scale score ≤2) between DEVT and IVEVT. There was no significant difference in mortality between all treatment groups. DEVT was associated with a 49% reduction in intracranial hemorrhage (ICH) compared with IVEVT (OR 0.51; 95% CI 0.33 to 0.79), due to reduction in rates of asymptomatic ICH (OR 0.47; 95% CI 0.29 to 0.76). Patients treated with DEVT had higher rates of reperfusion compared with IVEVT (OR 1.73; 95% CI 1.04 to 2.94). To our knowledge, this is the first network meta-analysis to be performed in the era of contemporary mechanical thrombectomy comparing DEVT and DEVTc. Our analysis suggests the addition of thrombolysis prior to thrombectomy for large vessel occlusions may not be associated with improved outcomes.

link

Journal of neurointerventional surgery 2019; 11(5): 443-449

Journal of neurointerventional surgery