Advertisement
Mayo Clinic Proceedings Home

Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-analysis

      Abstract

      Objective

      To consolidate the evidence from randomized trials for the use of endovascular therapy (ET) in patients with acute ischemic stroke.

      Methods

      We searched major databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus) from their inception to February 12, 2013, for randomized trials evaluating the efficacy of ET compared with standard of care for acute ischemic stroke. Pooled absolute and relative risk estimates were synthesized by using a random-effects model. Heterogeneity was assessed by using Q statistic and I2 statistic. Subset analysis was performed for patients with severe stroke (National Institutes of Health Stroke Scale score ≥20). The study was conducted from January 15, 2013 to April 30, 2013.

      Results

      Of the 1252 retrieved articles, 5 randomized trials enrolling 1197 patients with acute ischemic stroke were included. Seven hundred eleven patients received ET, and 486 received intravenous (IV) tissue plasminogen activator. There was no significant improvement in any of the outcomes in patients receiving ET compared with those receiving IV thrombolysis. On subgroup analysis, ET was found to have better outcomes in patients with severe stroke (National Institutes of Health Stroke Scale score ≥20), showing a dose-response gradient and improving excellent, good, and fair outcomes by an additional 4%, 7%, and 13%, respectively, compared with IV thrombolysis.

      Conclusion

      Overall, ET is not superior to IV thrombolysis for acute ischemic strokes (level B recommendation). However, ET showed promise and improved outcomes in patients with severe strokes, but the evidence is limited due to sample size. There is a need for further trials evaluating the role of ET in this high-risk group.

      Abbreviations and Acronyms:

      AAN (American Academy of Neurology), AIS (acute ischemic stroke), ET (endovascular therapy), IMS (Interventional Management of Stroke), IV (intravenous), mRS (modified Rankin Scale), MR-RESCUE (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy), NIHSS (National Institute of Health Stroke Scale), RCT (randomized controlled trial), RR (risk ratio), sICH (symptomatic intracranial hemorrhage), tPA (tissue plasminogen activator)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Executive summary: heart disease and stroke statistics–2012 update: a report from the American Heart Association.
        Circulation. 2012; 125: 188-197
        • The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
        Tissue plasminogen activator for acute ischemic stroke.
        N Engl J Med. 1995; 333: 1581-1587
        • Rha J.-H.
        • Saver J.L.
        The impact of recanalization on ischemic stroke outcome: a meta-analysis.
        Stroke. 2007; 38: 967-973
        • Chimowitz M.I.
        Endovascular treatment for acute ischemic stroke–still unproven.
        N Engl J Med. 2013; 368: 952-955
      1. Nam J, Jing H, O'Reilly D. Intra-arterial thrombolysis vs. standard treatment or intravenous thrombolysis in adults with acute ischemic stroke: a systematic review and meta-analysis [published online ahead of print January 7, 2013]. Int J Stroke. http://dx.doi.org/10.1111/j.1747-4949. 2012.00914.x. Accessed August 28, 2013.

        • Broderick J.P.
        • Palesch Y.Y.
        • Demchuk A.M.
        • et al.
        Endovascular therapy after intravenous t-PA versus t-PA alone for stroke.
        N Engl J Med. 2013; 368: 893-903
        • Ciccone A.
        • Valvassori L.
        • Nichelatti M.
        • et al.
        Endovascular treatment for acute ischemic stroke.
        N Engl J Med. 2013; 368: 904-913
        • Kidwell C.S.
        • Jahan R.
        • Gornbein J.
        • et al.
        A trial of imaging selection and endovascular treatment for ischemic stroke.
        N Engl J Med. 2013; 368: 914-923
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
      2. University of York, Center for Reviews and Dissemination. PROSPERO: International prospective register of systematic reviews. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013003838. Accessed August 2013.

        • Cohen J.A.
        Coefficient of agreement for nominal scales educational and psychological measurement.
        Educ Psychol Meas. 1960; 20: 37-46
        • van Swieten J.C.
        • Koudstaal P.J.
        • Visser M.C.
        • Schouten H.J.
        • van Gijn J.
        Interobserver agreement for the assessment of handicap in stroke patients.
        Stroke. 1988; 19: 604-607
        • Jadad A.R.
        • Moore R.A.
        • Carroll D.
        • et al.
        Assessing the quality of reports of randomized clinical trials: is blinding necessary?.
        Control Clin Trials. 1996; 17: 1-12
        • Kjaergard L.L.
        • Villumsen J.
        • Gluud C.
        Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses.
        Ann Intern Med. 2001; 135: 982-989
      3. Higgins J.P.T. Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. [updated March 2011]. The Cochrane Collaboration, 2011 (Accessed August 28, 2013)
        • Mazighi M.
        • Serfaty J.M.
        • Labreuche J.
        • et al.
        Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study.
        Lancet Neurol. 2009; 8: 802-809
        • Sun C.H.
        • Nogueira R.G.
        • Glenn B.A.
        • et al.
        “Picture to puncture”: a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke.
        Circulation. 2013; 127: 1139-1148
        • Gross R.A.
        • Johnston K.C.
        Levels of evidence: taking neurology to the next level.
        Neurology. 2009; 72: 8-10
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Ciccone A.
        • Valvassori L.
        • Ponzio M.
        • et al.
        Intra-arterial or intravenous thrombolysis for acute ischemic stroke? the SYNTHESIS pilot trial.
        J Neurointerv Surg. 2010; 2: 74-79
        • Sen S.
        • Huang D.Y.
        • Akhavan O.
        • Wilson S.
        • Verro P.
        • Solander S.
        IV vs. IA TPA in acute ischemic stroke with CT angiographic evidence of major vessel occlusion: a feasibility study.
        Neurocrit Care. 2009; 11: 76-81
        • Nordic Cochrane Centre, Cochrane Collaboration
        Review Manager (RevMan). 5.1.
        Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen2011
        • Sterne J.A.
        • Gavaghan D.
        • Egger M.
        Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature.
        J Clin Epidemiol. 2000; 53: 1119-1129
        • Nogueira R.G.
        • Lutsep H.L.
        • Gupta R.
        • et al.
        Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial.
        Lancet. 2012; 380: 1231-1240
        • Saver J.L.
        • Jahan R.
        • Levy E.I.
        • et al.
        Solitaire flow restoration device versus the Merci retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial.
        Lancet. 2012; 380: 1241-1249
        • Sheth K.N.
        • Terry J.B.
        • Nogueira R.G.
        • et al.
        Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes.
        J Neurointerv Surg. 2013; 5: i62-i65
        • Broussalis E.
        • Trinka E.
        • Hitzl W.
        • Wallner A.
        • Chroust V.
        • Killer-Oberpfalzer M.
        Comparison of stent-retriever devices versus the Merci retriever for endovascular treatment of acute stroke.
        Am J Neuroradiol. 2013; 34: 366-372