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Abstract
Objective: To compare the outcomes between endovascular and medical management of acute ischemic stroke in recent randomized controlled trials (RCT).
Methods: A systematic literature review was performed, and multicenter, prospective RCTs published from January 1, 2013, to May 1, 2015, directly comparing endovascular therapy to medical management for patients with acute ischemic stroke were included. Meta-analyses of modified Rankin Scale (mRS) and mortality at 90 days and symptomatic intracranial hemorrhage (sICH) for endovascular therapy and medical management were performed.
Results: Eight multicenter, prospective RCTs (Interventional Management of Stroke [IMS] III, Local Versus Systemic Thrombolysis for Acute Ischemic Stroke [SYNTHESIS] Expansion, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy [MR RESCUE], Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands [MR CLEAN], Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness [ESCAPE], Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial [EXTEND-IA], Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment [SWIFT PRIME], and Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours [REVASCAT]) comprising 2,423 patients were included. Meta-analysis of pooled data demonstrated functional independence (mRS 0–2) at 90 days in favor of endovascular therapy (odds ratio [OR] = 1.71; p = 0.005). Subgroup analysis of the 6 trials with large vessel occlusion (LVO) criteria also demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.23; p < 0.00001). Subgroup analysis of the 5 trials that primarily utilized stent retriever devices (≥70%) in the intervention arm demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.39; p < 0.00001). No difference was found for mortality at 90 days and sICH between endovascular therapy and medical management in all analyses and subgroup analyses.
Conclusions: This meta-analysis provides strong evidence that endovascular intervention combined with medical management, including IV tissue plasminogen activator for eligible patients, improves the outcomes of appropriately selected patients with acute ischemic stroke in the setting of LVO.
GLOSSARY
- AIS=
- acute ischemic stroke;
- ASPECTS=
- Alberta Stroke Program Early CT Score;
- CI=
- confidence interval;
- ESCAPE=
- Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness;
- EXTEND-IA=
- Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial;
- IA=
- intra-arterial;
- ICA=
- internal carotid artery;
- IMS III=
- Interventional Management of Stroke III;
- ITT=
- intent-to-treat;
- LVO=
- large vessel occlusion;
- MR CLEAN=
- Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands;
- MR RESCUE=
- Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy;
- mRS=
- modified Rankin Scale;
- NIHSS=
- NIH Stroke Scale;
- OR=
- odds ratio;
- RCT=
- randomized controlled trial;
- REVASCAT=
- Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours;
- sICH=
- symptomatic intracranial hemorrhage;
- SWIFT PRIME=
- Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment;
- SYNTHESIS=
- Local Versus Systemic Thrombolysis for Acute Ischemic Stroke;
- tPA=
- tissue plasminogen activator;
- TREVO 2=
- Trevo versus Merci Retrievers for Thrombectomy Revascularisation of Large Vessel Occlusions in Acute Ischaemic Stroke
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Supplemental data at Neurology.org
- Received May 26, 2015.
- Accepted in final form August 5, 2015.
- © 2015 American Academy of Neurology
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