Top

Clinical Neuroradiology

Published in:

Open Access 26-05-2023 | Stroke | Review Article

Endovascular Thrombectomy for Acute Stroke with a Large Ischemic Core: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Authors: Mohamed Abuelazm, Unaiza Ahmad, Husam Abu Suilik, Amith Seri, Abdelrahman Mahmoud, Basel Abdelazeem

Published in: Clinical Neuroradiology | Issue 3/2023

Abstract

Background

Endovascular thrombectomy (ET) efficacy and safety in stroke with a large ischemic core is still inconclusive as this population has been underrepresented in ET randomized controlled trials (RCTs).

Methods

We conducted a systematic review and meta-analysis synthesizing RCTs, which were retrieved by systematically searching: PubMed, Web of Science, SCOPUS, and Cochrane through February 18th, 2023. Our primary outcome was neurological disability measured by the modified Rankin scale (mRS). Dichotomous outcomes were pooled using risk ratio (RR) along with confidence interval (CI) using Revman V. 5.4 software.

Results

Three RCTs with a total of 1010 patients were included in our analysis. ET significantly increased the rates of functional independence (mRS ≤ 2) (RR: 2.54 with 95% CI [1.85, 3.48]), independent ambulation (mRS ≤ 3) (RR: 1.78 with 95% CI [1.28, 2.48]), and early neurological improvement (RR: 2.46 with 95% CI [1.60, 3.79]). However, there was no difference between endovascular thrombectomy and medical care in excellent neurological recovery (mRS ≤ 1) (RR: 1.35 with 95% CI [0.88, 2.08]). Also, ET significantly reduced the rate of poor neurological recovery (mRS 4–6) (RR: 0.79 with 95% CI [0.72, 0.86]). However, endovascular thrombectomy was associated with more incidence of any intracranial hemorrhage (RR: 2.40 with 95% CI [1.90, 3.01] [0.72, 0.86]).

Conclusion

ET combined with medical care was associated with better functional outcomes compared with medical care alone. However, ET was associated with a higher rate of intracranial hemorrhage. This can support extending ET indication in the management of stroke with a large ischemic core.

Available only for authorised users

Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18. https://doi.org/10.1056/nejmoa1414792.CrossRefPubMed

Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30. https://doi.org/10.1056/nejmoa1414905.CrossRefPubMed

Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306. https://doi.org/10.1056/nejmoa1503780.CrossRefPubMed

Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t‑PA vs. t‑PA alone in stroke. N Engl J Med. 2015;372:2285–95. https://doi.org/10.1056/nejmoa1415061.CrossRefPubMed

Olvert A. Berkhemer, M.D., Puck S.S. Fransen, M.D., Debbie Beumer, M.D., Lucie A. van den Berg, M.D., Hester F. Lingsma, Ph.D., Albert J. Yoo, M.D., Wouter J. Schonewille, M.D., Jan Albert Vos, M.D., Ph.D., Paul J. Nederkoorn, M.D., Ph.D., Marieke J.H. We et al. (2015) A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med 372:394–394. https://doi.org/10.1056/nejmx140064.

Pexman JHW, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. Am J Neuroradiol. 2001;22:1534–42.PubMedPubMedCentral

Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, Hasegawa Y, Ohata K, Shiokawa Y, Nozaki K, Ezura M, Iwama T. JSS/JNS/JSNET Joint Guideline Authoring Committee. Guidelines for Mechanical Thrombectomy in Japan, the Fourth Edition, March 2020: A Guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo). 2021;61(3):163–192. https://doi.org/10.2176/nmc.nmc.st.2020-0357. Epub 2021.CrossRef

Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the early management of patients with acute ischemic stroke 2019 update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke. 2019;50:3331–2. https://doi.org/10.1161/STROKEAHA.119.027708.CrossRefPubMed

Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378:708–18. https://doi.org/10.1056/nejmoa1713973.CrossRefPubMedPubMedCentral

10.

Lindsay E. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. J Emerg Med. 2018;54:583–4. https://doi.org/10.1016/j.jemermed.2018.02.029.CrossRef

11.

Bracard S, Ducrocq X, Mas JL, et al (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15:1138–1147. https://doi.org/10.1016/S1474-4422(16)30177‑6.

12.

Goyal M, Menon BK, Van Zwam WH, et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731. https://doi.org/10.1016/S0140-6736(16)00163‑X.

13.

Cucchiara B, Kasner SE, Tanne D, et al. Factors Associated With Intracerebral Hemorrhage After Thrombolytic Therapy for Ischemic. Stroke Stroke. 2009;40:3067–72. https://doi.org/10.1161/strokeaha.109.554386.CrossRefPubMed

14.

Sarraj A, Hassan AE, Savitz S, et al. Outcomes of Endovascular Thrombectomy vs Medical Management Alone in Patients With Large Ischemic Cores. JAMA Neurol. 2019;76:1147. https://doi.org/10.1001/jamaneurol.2019.2109.CrossRefPubMedPubMedCentral

15.

Kerleroux B, Janot K, Hak JF, et al. Mechanical thrombectomy in patients with a large ischemic volume at presentation: Systematic review and meta-analysis. J Stroke. 2021;23:358–66. https://doi.org/10.5853/jos.2021.00724.CrossRefPubMedPubMedCentral

16.

Campbell BCV, Majoie CBLM, Albers GW, et al (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data. Lancet Neurol 18:46–55. https://doi.org/10.1016/S1474-4422(18)30314‑4.

17.

Román LS, Menon BK, Blasco J, et al (2018) Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 17:895–904. https://doi.org/10.1016/S1474-4422(18)30242‑4.

18.

Sarraj A, Grotta JC, Pujara DK, et al. Triage imaging and outcome measures for large core stroke thrombectomy—A systematic review and meta-analysis. J Neurointerv Surg. 2020;12:1172–9. https://doi.org/10.1136/neurintsurg-2019-015509.CrossRefPubMed

19.

Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386:1303–13. https://doi.org/10.1056/nejmoa2118191.CrossRefPubMed

20.

Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med. 2023; https://doi.org/10.1056/NEJMoa2213379.CrossRefPubMed

21.

Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med. 2023; https://doi.org/10.1056/NEJMoa2214403.CrossRefPubMed

22.

Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; https://doi.org/10.1136/BMJ.N71.CrossRefPubMedPubMedCentral

23.

Higgins JPT, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions. Cochrane Handb Syst Rev Interv. 2019. pp. 1–694. https://doi.org/10.1002/9781119536604.CrossRef

24.

Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; https://doi.org/10.1136/BMJ.L4898.CrossRefPubMedPubMedCentral

25.

Guyatt GH, Oxman AD, Kunz R, et al (2008) Rating Quality of Evidence and Strength of Recommendations: What is “quality of evidence” and why is it important to clinicians? BMJ Br Med J 336:995. https://doi.org/10.1136/BMJ.39490.551019.BE.

26.

Guyatt GH, Oxman AD, Vist GE, et al (2008) Rating Quality of Evidence and Strength of Recommendations: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ Br Med J 336:924. https://doi.org/10.1136/BMJ.39489.470347.AD.

27.

RevMan | Cochrane Training. https://training.cochrane.org/online-learning/core-software-cochrane-reviews/revman. Accessed 3 Aug 2021.

28.

Cochrane Handbook for Systematic Reviews. Intervention. 2022. https://doi.org/10.1002/9780470712184.

29.

Charbonnier G, Bonnet L, Biondi A, Moulin T. Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke. Front Neurol. 2021; https://doi.org/10.3389/fneur.2020.629920.CrossRefPubMedPubMedCentral

Title: Endovascular Thrombectomy for Acute Stroke with a Large Ischemic Core: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Authors: Mohamed Abuelazm
Unaiza Ahmad
Husam Abu Suilik
Amith Seri
Abdelrahman Mahmoud
Basel Abdelazeem
Publication date: 26-05-2023
Publisher: Springer Berlin Heidelberg
Keywords: Stroke
Thrombectomy
Published in: Clinical Neuroradiology / Issue 3/2023
Print ISSN: 1869-1439
Electronic ISSN: 1869-1447
DOI: https://doi.org/10.1007/s00062-023-01306-x

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Endovascular Thrombectomy for Acute Stroke with a Large Ischemic Core: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 3/2023

Preoperative Embolization of Meningiomas Facilitates Reduced Surgical Complications and Improved Clinical Outcomes

Farewell to Companions

Blood Flow Velocity: a Decision Tool for Stenting Indication in Venous Pulsatile Tinnitus

Maximizing the Available Space

Angiographic Index for the Treatment Efficacy and Functional Outcomes of Spinal Cord Arteriovenous Shunts: the Vertebral Blush Sign

In Memory of Prof. Dr. med. Antonios Valavanis