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Endovascular therapy improves functional outcomes, not mortality, after acute ischemic stroke
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Compared with standard care, endovascular intervention with a thrombectomy device improved functional outcomes in patients with acute ischemic stroke but did not affect all-cause mortality or intracranial hemorrhage, according to a new meta-analysis.
Researchers analyzed eight trials of a total of 2,423 patients (mean age, 67.4 years; 46.7% women) with acute ischemic stroke comparing endovascular therapy with a mechanical thrombectomy device (n = 1,313) vs. standard care that included administration of IV tissue plasminogen activator (tPA) (n = 1,110). The outcomes of interest were improvement in modified Rankin scale score at 90 days; functional independence, defined as a modified Rankin scale score of 0 to 2; angiographic revascularization at 24 hours; and symptomatic intracranial hemorrhage and all-cause mortality at 90 days.
Jetan H. Badhiwala, MD, and colleagues found that those receiving endovascular thrombectomy were more likely to have improvement in modified Rankin scale score at 90 days compared with those receiving standard care (OR = 1.56; 95% CI, 1.14-2.13).
They also observed functional independence at 90 days in 44.6% of the thrombectomy group (95% CI, 36.6-52.8) vs. 31.8% of the standard care group (95% CI, 24.6-40; risk difference, 12%; 95% CI, 3.8-20.3; OR = 1.71; 95% CI, 1.18-2.49).
Endovascular thrombectomy was associated with higher rates of angiographic revascularization at 24 hours than standard care (75.8% vs. 34.1%; OR = 6.49; 95% CI, 4.79-8.79), according to Badhiwala, from the division of neurosurgery at the University of Toronto, and colleagues.
However, they found no differences between the groups in the 90-day rates of symptomatic intracranial hemorrhage (thrombectomy group, 5.7%; standard care group, 5.1%; OR = 1.12; 95% CI, 0.77-1.63) or all-cause mortality (thrombectomy group, 15.8%; standard care group, 17.8%; OR = 0.87; 95% CI, 0.68-1.12).
In a related editorial, Joanna M. Wardlaw, MD, FRCR, and Martin S. Dennis, MD, FRCP, both from the Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, noted that limitations of the meta-analysis include significant heterogeneity for functional outcomes; wide CIs for intracranial hemorrhage and death; and that five of the eight trials were stopped early, which may exaggerate the observed treatment effect.
They also wrote that the latest time in which some patients might benefit from endovascular thrombectomy is not yet known. “This is very important because patient transfer to specialist centers for thrombectomy will inevitably introduce delays,” they wrote.
“Additional rigorous trials would help to define which additional patients might benefit from thrombectomy and by how much, including consideration of the effects of comorbidities, advanced age, limits of extractable thrombus location or extent and the latest time window (probably > 6 hours),” they concluded. ˗ by Erik Swain
Disclosure: The researchers, Wardlaw and Dennis report no relevant financial disclosures.
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