Direct thrombectomy, bridging therapy confer similar functional outcomes in stroke

Results of a meta-analysis published in Neurology determined there was no difference in functional outcomes between direct thrombectomy and combination with bridging IV thrombolysis among Asian patients with large vessel occlusion stroke.

“The safety and efficacy of intravenous thrombolysis (IVT) for patients with large vessel occlusion (LVO) who are also eligible for endovascular stroke treatment has been questioned,” Aristeidis Katsanos, MD, a neurologist and stroke fellow at McMaster University and the Population Health Research Institute, and colleagues wrote. “Direct endovascular thrombectomy (dEVT), bypassing the administration of any intravenous thrombolytic agent, has been suggested as an alternative therapeutic approach to the combination of IVT followed by endovascular treatment for acute ischemic stroke (AIS) patients who are eligible for both treatment modalities and present at a site that can offer prompt endovascular treatment. The hypothesis that dEVT is a non-inferior option to the current standard of care combination of IVT and endovascular thrombectomy, referred also as bridging therapy (BT), has been evaluated in the setting of multiple observational studies and recently published randomized-controlled clinical trials (RCTs).”

Katsanos and colleagues conducted a systematic review and meta-analysis to assess the current evidence on the relative efficacy and safety of dEVT compared with BT in Asian patients with AIS. They noted a median age of 70 years in the overall study population; 44% were women.

The study included patients with LVO AIS who were eligible for both therapeutic options presenting within 4.5 hours from stroke onset. Through searching Medline and Scopus, investigators identified three randomized controlled trials that included a total of 1,092 patients. The probability of a modified Rankin scale (mRS) score of 0-2 at 3 months served as the primary outcome.

Investigators observed no different between dEVT and BT with regard to outcomes of mRS 0-2 (OR = 1.08; 95% CI, 0.85-1.38; adjusted OR = 1.11; 95% CI, 0.76-1.63), mRS 0-1 (OR = 1.10; 95% CI, 0.84-1.43; adjusted OR = 1.16; 95% CI, 0.84-1.61) and functional improvement at 3 months (common OR = 1.08; 95% CI, 0.88-1.34; adjusted common OR = 1.09; 95% CI, 0.86-1.37). Katsanos and colleagues noted patients who received dEVT compared with BT had a significantly poorer chance of successful recanalization prior to the endovascular procedure (OR = 0.37; 95% CI, 0.18-0.77).

According to researchers, although patients who received dEVT compared with BT had reduced intracranial bleeding rates (OR = 0.67; 95% CI, 0.49-0.92), there was no significant difference in the likelihood of symptomatic intracranial hemorrhage. They also reported no differences between the groups regarding all-cause mortality, serious adverse events or procedural complications.

“Effect estimates from available RCTs, presented in the current systematic review and meta-analysis, when compared to those provided by observational studies, raise concerns for heterogeneity in inclusion criteria and the possibility for selection bias within published cohorts,” Katsanos and colleagues wrote. “… The issue of generalizability of the evidence from individual RCTs and the results from the current meta-analysis beyond the Asian population deserves particular attention.”