Abstract
Backgroundand Purpose Recent randomized controlled trials have demonstrated consistent effectiveness of endovascular treatment (EVT) for acute ischemic stroke, leading to update on stroke management guidelines. We conducted this meta-analysis to assess the efficacy and safety of EVT overall and in subgroups stratified by age, baseline stroke severity, brain imaging feature, and anesthetic type.MethodsPublished randomized controlled trials comparing EVT and standard medical care alone were evaluated. The measured outcomes were 90-day functional independence (modified Rankin Scale ≤2), all-cause mortality, and symptomatic intracranial hemorrhage.ResultsNine trials enrolling 2476 patients were included (1338 EVT, 1138 standard medical care alone). For patients with large vessel occlusions confirmed by noninvasive vessel imaging, EVT yielded improved functional outcome (pooled odds ratio [OR], 2.02; 95% confidence interval [CI], 1.64–2.50), lower mortality (OR, 0.75; 95% CI, 0.58–0.97), and similar symptomatic intracranial hemorrhage rate (OR, 1.12; 95% CI, 0.72–1.76) compared with standard medical care. A higher proportion of functional independence was seen in patients with terminus intracranial artery occlusion (±M1) (OR, 3.16; 95% CI, 1.64–6.06), baseline Alberta Stroke Program Early CT score of 8–10 (OR, 2.11; 95% CI, 1.25–3.57) and age ≤70 years (OR, 3.01; 95% CI, 1.73–5.24). EVT performed under conscious sedation had better functional outcomes (OR, 2.08; 95% CI, 1.47–2.96) without increased risk of symptomatic intracranial hemorrhage or short-term mortality compared with general anesthesia.ConclusionsVessel-imaging proven large vessel occlusion, a favorable scan, and younger age are useful predictors to identify anterior circulation stroke patients who may benefit from EVT. Conscious sedation is feasible and safe in EVT based on available data. However, firm conclusion on the choice of anesthetic types should be drawn from more appropriate randomized controlled trials.
Highlights
For patients with large vessel occlusions confirmed by noninvasive vessel imaging, endovascular treatment (EVT) yielded improved functional outcome, lower mortality (OR, 0.75; 95% confidence intervals (CIs), 0.58–0.97), and similar symptomatic intracranial hemorrhage rate (OR, 1.12; 95% CI, 0.72–1.76) compared with standard medical care
A higher proportion of functional independence was seen in patients with terminus intracranial artery occlusion (±M1) (OR, 3.16; 95% CI, 1.64–6.06), baseline Alberta Stroke Program Early CT score of 8–10 (OR, 2.11; 95% CI, 1.25–3.57) and age 70 years (OR, 3.01; 95% CI, 1.73–5.24)
EVT performed under conscious sedation had better functional outcomes (OR, 2.08; 95% CI, 1.47–2.96) without increased risk of symptomatic intracranial hemorrhage or short-term mortality compared with general anesthesia
Summary
Endovascular treatment (EVT) with either mechanical devices or intra–arterial thrombolysis to remove or dissolve blood clots has long been regarded as a potent therapy for acute ischemic stroke, especially for patients with intracranial large vessel occlusion (LVO) resistant to intravenous recombinant tissue–type plasminogen activator (rt–PA).[1,2,3] three initial randomized controlled trials (RCTs) failed to show a benefit of EVT compared with intravenous rt–PA, leading to widespread pessimism in the neurological community about the interventional therapy.[4,5,6] The lack of confirmed intracranial artery occlusions by pretreatment vessel imaging, use of early–generation mechanical devices, delayed treatment initiation, and non–consecutive subject enrollment were considered to contribute significantly to these neutral results.[7]. Uncertainty and controversy still remain about the impact of age, stroke severity, occlusion site, and anesthetic types on EVT outcomes and quantitative evidence from existing RCTs are lacking. We performed this meta–analysis to evaluate the efficacy and safety of EVT overall and in pre-specified subgroups with available data. Recent randomized controlled trials have demonstrated consistent effectiveness of endovascular treatment (EVT) for acute ischemic stroke, leading to update on stroke management guidelines We conducted this meta-analysis to assess the efficacy and safety of EVT overall and in subgroups stratified by age, baseline stroke severity, brain imaging feature, and anesthetic type.
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