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Bridging versus Direct Mechanical Thrombectomy in Acute Ischemic Stroke: A Subgroup Pooled Meta-Analysis for Time of Intervention, Eligibility, and Study Design.
- Source :
-
Cerebrovascular diseases (Basel, Switzerland) [Cerebrovasc Dis] 2020; Vol. 49 (2), pp. 223-232. Date of Electronic Publication: 2020 Apr 24. - Publication Year :
- 2020
-
Abstract
- Background and Aim: The risk/benefit profile of intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) in acute ischemic stroke is still unclear. We provide a systematic review and meta-analysis including studies comparing direct EVT (dEVT) vs. bridging treatment (IVT + EVT), defining the impact of treatment timing and eligibility to IVT on functional status and mortality.<br />Methods: Protocol was registered with PROSPERO (CRD42019135915) and followed PRISMA guidelines. PubMed, EMBASE, and Cochrane Central were searched for randomized controlled trials (RCTs), retrospective, and prospective studies comparing IVT + EVT vs. dEVT in adults (≥18) with acute ischemic stroke. Primary endpoint was functional independence at 90 days (modified Rankin Scale <3); secondary endpoints were (i) good recanalization (thrombolysis in cerebral infarction >2a), (ii) mortality, and (iii) symptomatic intracranial hemorrhage (sICH). Subgroup analysis was performed according to study type, eligibility to IVT, and onset-to-groin timing (OGT), stratifying studies for similar OGT. ORs for endpoints were pooled with meta-analysis and compared between reperfusion strategies.<br />Results: Overall, 35 studies were included (n = 9,117). No significant differences emerged comparing patients undergoing dEVT and bridging treatment for gender, hypertension, diabetes, National Institute of Health Stroke Scale score at admission. Regarding primary endpoint, IVT + EVT was superior to dEVT (OR 1.44, 95% CI 1.22-1.69, p < 0.001, pheterogeneity<0.001), with number needed to treat being 18 in favor of IVT + EVT. Results were confirmed in studies with similar OGT (OR 1.66; 95% CI 1.21-2.28), shorter OGT for IVT + EVT (OR 1.53, 95% CI 1.27-1.85), and independently from IVT eligibility (OR 1.53, 95% CI 1.29-1.82). Mortality at 90 days was higher in dEVT (OR 1.38; 95% CI 1.09-1.75), but no significant difference was noted for sICH. However, considering data from RCT only, reperfusion strategies had similar primary (OR 0.91, 95% CI 0.6-1.39) and secondary endpoints. Differences in age and clinical severity across groups were unrelated to the primary endpoint.<br />Conclusions: Compared to dEVT, IVT + EVT associates with better functional outcome and lower mortality. Post hoc data from RCTs point to substantial equivalence of reperfusion strategies. Therefore, an adequately powered RCTs comparing dEVT versus IVT + EVT are warranted.<br /> (© 2020 S. Karger AG, Basel.)
- Subjects :
- Aged
Aged, 80 and over
Brain Ischemia diagnosis
Brain Ischemia mortality
Brain Ischemia physiopathology
Eligibility Determination
Female
Humans
Male
Middle Aged
Recovery of Function
Risk Assessment
Risk Factors
Stroke diagnosis
Stroke mortality
Stroke physiopathology
Time Factors
Treatment Outcome
Brain Ischemia therapy
Clinical Decision-Making
Endovascular Procedures adverse effects
Endovascular Procedures mortality
Fibrinolytic Agents administration & dosage
Research Design
Stroke therapy
Thrombectomy adverse effects
Thrombolytic Therapy adverse effects
Thrombolytic Therapy mortality
Time-to-Treatment
Subjects
Details
- Language :
- English
- ISSN :
- 1421-9786
- Volume :
- 49
- Issue :
- 2
- Database :
- MEDLINE
- Journal :
- Cerebrovascular diseases (Basel, Switzerland)
- Publication Type :
- Academic Journal
- Accession number :
- 32335550
- Full Text :
- https://doi.org/10.1159/000507844