Reperfusion and Clinical Outcomes in Acute Ischemic Stroke: Systematic Review and Meta-Analysis of the Stent-Retriever-Based, Early Window Endovascular Stroke Trials.

Nathan W Manning,Philip M Meyers,Charles D Warne

doi:10.3389/fneur.2018.00301

Abstract

To explore the effects of reperfusion grade rates on clinical outcomes in the setting of stent-retriever-based reperfusion therapy for anterior circulation stroke in early time windows. Systematic searching of Medline and Embase databases was performed to identify stroke trials of stent-retriever-based therapy versus standard care. Mixed effects meta-regression was used to analyze the trial-level association between reperfusion rates and clinical outcomes. A total of five trials met the inclusion criteria (n = 1,287). Rates of successful reperfusion [modified thrombolysis in cerebral ischemia grade 2b/3] demonstrated strong evidence for an association with good functional outcomes [modified Rankin scale score (mRS) 0-2] OR 1.59 (95% CI 1.16, 2.19) p = 0.019 and very strong evidence for an association with excellent functional outcomes (mRS 0-1) OR 2.10 (95% CI 1.46, 3.01) p = 0.007. In addition, there was weak evidence for an association with symptomatic intracranial hemorrhage OR 0.54 (95% CI 0.28, 1.04) p = 0.057 and mortality OR 0.69 (95% CI 0.69, 1.01) p = 0.053. In early, stent-retriever-based acute ischemic stroke treatment, reperfusion appears to be a major predictor of outcomes. Every 10% increase in the rates of successful reperfusion is associated with an 11% increase in the probability of achieving good and 17% increase in the probability of achieving excellent outcomes. Symptomatic intracranial hemorrhage and mortality may be decreased as reperfusion rates are improved.

Highlights

Stent-retriever-based mechanical thrombectomy has become the standard of care for anterior circulation, large vessel occlusion strokes [1,2,3,4,5]
The use of stent-retrievers is associated with markedly higher rates of modified thrombolysis in cerebral ischemia grade 2b/3 reperfusion, which has previously been noted to correlate with trial success [10]
The five included trials randomized a total of 1,287 patients to receive either the control or intervention

Summary

Introduction

Stent-retriever-based mechanical thrombectomy has become the standard of care for anterior circulation, large vessel occlusion strokes [1,2,3,4,5]. In studies limited to the use of stent-retrievers, the effect of time is greatly reduced [7]. The use of stent-retrievers is associated with markedly higher rates of modified thrombolysis in cerebral ischemia (mTICI) grade 2b/3 reperfusion, which has previously been noted to correlate with trial success [10]. Successful reperfusion is associated with less infarct core growth and improved functional outcomes [11]. This may help explain the treatment effect of the recent trials. We use meta-regression analysis to explore the association between reperfusion grade rates and outcomes in the stentretriever-based randomized controlled trials in early treatment windows

Methods

Results

Discussion

Conclusion