Abstract W P25: A Meta-analysis of Randomised Controlled Trials of Endovascular Treatment for Acute Ischaemic Stroke

Abstract

Introduction: Initial randomised controlled trials (RCTs) showed endovascular treatment of acute ischaemic stroke (AIS) to improve recanalization and functional outcome but recent RCTs have failed to show clinical benefit. Methods: MEDLINE, EMBASE and Cochrane databases were searched for RCTs of endovascular treatment for AIS. Additional RCTs were identified from bibliographies of retrieved articles. Data was extracted on patient characteristics, study intervention, 90-day functional outcome and mortality, 24-hour symptomatic intracerebral haemorrhage (sICH), and post-procedural recanalization. Studies were reviewed independently by 2 trained readers and RCTs of differing methodology were evaluated separately to maintain homogeneity. Results: 12 RCTs were identified with 1910 subjects (mean(SD) age 65(3); 58% male; median(IQR) baseline NIHSS 17(3)) and mean(SD) time for endovascular intervention 4.9(2.9) hours. In 4 RCTs (n=350) comparing intra-arterial thrombolysis (IAT) with no thrombolysis, patients treated with IAT had significantly improved 90-day modified Rankin scale (mRS)<1 (OR: 1.68; 95% CI: 1.20-2.34), 90-day mRS<2 (OR: 1.98; 95% CI: 1.21-3.24) and recanalization (OR: 3.71; 95% CI: 2.80-4.93), reduced 90-day mortality (OR: 0.67; 95% CI: 0.47-0.96) but increased 24-hour sICH (OR: 4.65; 95% CI: 2.73-7.59). In 2 RCTs (n=201) comparing stent-retriever with clot-retrieval devices, patients treated with stent-retrievers had significantly improved 90-day mRS<1 (OR: 1.69; 95% CI: 1.11-2.58), 90-day mRS<2 (OR: 2.56; 95% CI: 1.49-4.38) and recanalization (OR: 1.60; 95% CI: 1.19-2.16), a trend to reduced 90-day mortality (OR: 0.66; 95% CI: 0.41-1.04) and no significant difference in 24-hour sICH (OR: 0.68; 95% CI: 0.18-2.57). No significant differences in patient outcomes were demonstrated in analyses of 3 RCTs (n=443) comparing IAT with intravenous thrombolysis (IVT) or 3 RCTs (n=809) incorporating combined IAT and IVT interventions. Conclusions: IAT for AIS improves recanalization, functional outcome and mortality compared with placebo but not compared with or in addition to IVT. For patients receiving endovascular intervention, stent-retriever devices provide better outcome data than clot-retrieval devices.