The perioperative complications and short-term death in endovascular treatment for acute stroke induced by extracranial carotid occlusion: a systematic review and a meta-analysis.

Abstract

Endovascular treatment (EVT) has been demonstrated superior to pharmacological thrombolysis in acute ischemic stroke (AIS) induced by extracranial internal carotid artery occlusion. This paper aims to summarize clinical evidence about EVT and assess its efficacy and safety on acute extracranial carotid occlusion. We systematically reviewed all studies that reported endovascular therapy as carotid stenting, stent retriever, aspiration, and angioplasty for acute extracranial carotid occlusion. Literature retrieval was performed in PubMed, Embase, and Cochrane library, dated from January 1st, 2005 to December 31st, 2020. The primary endpoint was a favorable outcome rate. Major secondary endpoints were SICH incidence, 90-day mortality rate, and complications. Meta-analysis and subgroup analysis were conducted to identify predictors for prognosis. This systematic review has been registered in PROSPERO (CRD42020181154) on July 18, 2020. 10 studies with 620 patients were included in total. Endovascular approach presented a favorable outcome rate of 0.47 (0.37, 0.56), an acceptable 90-day mortality rate of 0.16 (0.13, 0.19), and a mild SICH rate of 0.07 (0.05, 0.10). Age and NIHSS at admission were negatively associated with favorable outcome, with odds ratio of 0.95 (0.92, 0.98) and 0.74 (0.62, 0.88) respectively. Lower age (p=0.049) and aspiration thrombectomy (p=0.041) predicted less SICH events. In subgroup in which time window > 6 hours, endovascular therapy presented similar encouraging results, with favorable outcome rate of 0.59 (0.51, 0.66), 90-day mortality rate of 0.11 (0.07, 0.17), and SICH rate of 0.04 (0.02, 0.09). EVT can effectively improve neurological function and reduce 90-day mortality for acute extracranial carotid occlusion patients without increasing the risk of symptomatic intracranial hemorrhage. Endovascular therapy is safe to perform from 6 to 24 hours after symptom onset.