Dataset Information

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

ABSTRACT:

Introduction

Endovascular thrombectomy (EVT) is a well-established and effective therapeutic option for patients that meet certain criteria. However, this modality is not well studied in patients with pre-existing disability. The aim of the present study was to investigate the impact of mechanical thrombectomy in patients with acute onset ischemic stroke and pre-stroke dependency (PSD) in regard to their clinical outcome and mortality.

Materials and methods

The MEDLINE, Scopus, and Cochrane Library databases were comprehensively searched with a cut-off date of December 11th, 2021. We performed meta-analysis to investigate the 90-day clinical outcome, the 90-day mortality, and the rate of symptomatic intracerebral hemorrhage (sICH) between the PSD (modified Rankin Scale score ≥ 3) and non-PSD (modified Rankin Scale score = 0-2) groups who underwent EVT for acute onset ischemic stroke.

Results

Six studies were included in the meta-analysis involving 4,543 cases with no PSD and 591 cases with PSD. The non-PSD group showed a statistically significant better clinical outcome at 90 days compared to the PSD group [RR (95% CI) = 1.44 (1.06, 1.85); p _z = 0.02]. The non-PSD group demonstrated a statistically significant lower risk of death at 90 days in comparison to the PSD group [RR (95% CI) = 0.45 (0.41, 0.50); p _z < 0.01]. Lastly, the rate of sICH was comparable between the two groups [RR (95% CI) = 0.89 (0.64, 1.24); p _z = 0.48].

Discussion

We report a higher rate of unfavorable clinical outcome and a higher mortality rate in patients with PSD undergoing EVT compared to those with no previous disability. However, there was a significant proportion of PSD cases who fared well post-procedurally, indicating that PSD patients should not be routinely excluded from mechanical thrombectomy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021284181, identifier: CRD42021284181.

SUBMITTER: Adamou A

PROVIDER: S-EPMC9097509 | biostudies-literature | 2022

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Adamou Antonis A Gkana Androniki A Mavrovounis Georgios G Beltsios Eleftherios T ET Kastrup Andreas A Papanagiotou Panagiotis P

Frontiers in neurology 20220428

<h4>Introduction</h4>Endovascular thrombectomy (EVT) is a well-established and effective therapeutic option for patients that meet certain criteria. However, this modality is not well studied in patients with pre-existing disability. The aim of the present study was to investigate the impact of mechanical thrombectomy in patients with acute onset ischemic stroke and pre-stroke dependency (PSD) in regard to their clinical outcome and mortality.<h4>Materials and methods</h4>The MEDLINE, Scopus, an ...[more]

PMID: 35572918

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Project description:ImportanceAlthough endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality.ObjectiveTo identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis.Data sourcesAll randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines.Study selectionTen American Stroke Association/American Heart Association guideline-relevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT.Data extraction and synthesisData were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs.Main outcomes and measuresRisk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward).ResultsIn 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98; P = .03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01; P = .06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40; P = .38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72; P = .65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials.Conclusions and relevanceThis meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.

Project description:Background and purpose: It is unclear whether endovascular thrombectomy alone compared with intravenous thrombolysis combination with endovascular thrombectomy can achieve similar neurological outcomes in patients with acute large vessel occlusion stroke. We aimed to perform a systematic review and meta-analysis of randomized controlled trials to compare endovascular thrombectomy alone or intravenous thrombolysis plus endovascular thrombectomy in this population. Methods: We systematically searched PubMed, Embase, and ClinicalTrials.gov. We restricted our search to randomized clinical trials that examined the clinical outcomes of endovascular thrombectomy alone vs. intravenous thrombolysis plus endovascular thrombectomy. The Cochrane risk of bias tool was used to assess study quality. Random-effects meta-analyses were used for evaluating all outcomes. Results: Total three randomized controlled trials with 1,092 individuals enrolled were included in the meta-analysis, including 543 (49.7%) who received endovascular thrombectomy alone and 549 (50.3%) who received intravenous thrombolysis plus endovascular thrombectomy. The primary outcome of 90-day functional independence (modified Rankin scale (mRS) score ≤ 2) was 44.6% (242/543) in the endovascular thrombectomy alone group vs. 42.8% (235/549) in the alteplase with endovascular thrombectomy group (odds ratio (OR), 1.08 [95% CI, 0.85-1.38]; P = 0.0539). Among pre-specified secondary outcomes, no significant between-group differences were found in excellent outcome (mRS score ≤ 1) (OR, 1.12 [95% CI, 0.85-1.47]; P = 0.418), mortality at 90 days (OR, 0.93 [95% CI, 0.68-1.29]; P = 0.673), successful reperfusion (thrombolysis in cerebral infarction 2b-3) (OR, 0.75 [95% CI, 0.54-1.05]; P = 0.099), and symptomatic intracranial hemorrhage (OR, 0.72 [95% CI, 0.45-1.15]; P = 0.171). Conclusions: Among patients with acute ischemic stroke in the anterior circulation within 4.5 h from the onset, endovascular thrombectomy alone was non-inferior to combined intravenous thrombolysis and endovascular thrombectomy.

Project description:BackgroundThe current guideline recommended the use of intravenous thrombolysis (IVT) before Endovascular thrombectomy (EVT), but the effectiveness and safety of tenecteplase compare to alteplase in patients before EVT remain uncertain.MethodsWe searched PubMed, Embase, Web of Science, and the Cochrane Library to identify eligible articles from inception until September 16, 2023. The primary outcome was functional independence (mRS 0-2) at 90 days. Secondary outcomes included excellent outcome (mRS 0-1) at 90 days, all-cause mortality at follow-up, successful reperfusion (TICI 2b-3) after the end of EVT, symptomatic intracranial hemorrhage (sICH) or any intracranial hemorrhage (aICH). The PROSPERO registration number is CRD42023470419.ResultsEight randomized controlled trials (RCTs) were included involving 2,836 acute ischemic stroke (AIS) patients. Compared to EVT alone, tenecteplase (0.25 mg/kg and 0.4 mg/kg) + EVT and 0.9 mg/kg alteplase + EVT were significant difference associated with higher successful reperfusion (TICI 2b-3) after the end of EVT (RR = 2.31; 95% CI 1.15-4.63; RR = 2.31; 95% CI 1.00-5.33; RR = 1.05; 95% CI 1.01-1.09). And compared to 0.25 mg/kg tenecteplase + EVT, alteplase (0.6 mg/kg and 0.9 mg/kg) + EVT were significant difference associated with lower successful reperfusion (TICI 2b-3) after the end of EVT (RR = 0.45; 95% CI 0.22-0.90; RR = 0.45; 95% CI 0.23-0.91). The risk of aICH (RR = 1.50; 95% CI 1.07-2.09) was significantly higher for 0.6 mg/kg alteplase + EVT than EVT alone. There was no significant difference in functional independence (mRS 0-2), excellent outcome (mRS 0-1), all-cause mortality or sICH among the different IVT strategies (0.25 mg/kg or 0.4 mg/kg tenecteplase and 0.6 mg/kg or 0.9 mg/kg alteplase) before EVT.ConclusionThe use of alteplase before EVT may potentially improve the successful reperfusion after EVT compared to tenecteplase. Due to the insufficient sample size, more high-quality RCTs are needed to confirm effectiveness and safety of tenecteplase compare to alteplase in patients before EVT.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42023470419.

Project description:BackgroundNeuroinflammatory response contributes to early neurological deterioration (END) and unfavorable long-term functional outcome in patients with acute ischemic stroke (AIS) who recanalized successfully by endovascular thrombectomy (EVT), but there are no reliable biomarkers for their accurate prediction. Here, we sought to determine the temporal plasma profiles of the bioactive lipid mediators lipoxin A4 (LXA4), resolvin D1 (RvD1), and leukotriene B4 (LTB4) for their associations with clinical outcome.MethodsWe quantified levels of LXA4, RvD1, and LTB4 in blood samples retrospectively and longitudinally collected from consecutive AIS patients who underwent complete angiographic recanalization by EVT at admission (pre-EVT) and 24 hrs post-EVT. The primary outcome was unfavorable long-term functional outcome, defined as a 90-day modified Rankin Scale score of 3-6. Secondary outcome was END, defined as an increase in National Institutes of Health Stroke Scale (NIHSS) score ≥4 points at 24 hrs post-EVT.ResultsEighty-one consecutive AIS patients and 20 healthy subjects were recruited for this study. Plasma levels of LXA4, RvD1, and LTB4 were significantly increased in post-EVT samples from AIS patients, as compared to those of healthy controls. END occurred in 17 (20.99%) patients, and 38 (46.91%) had unfavorable 90-day functional outcome. Multiple logistic regression analyses demonstrated that post-EVT levels of LXA4 (adjusted odd ratio [OR] 0.992, 95% confidence interval [CI] 0.987-0.998), ΔLXA4 (adjusted OR 0.995, 95% CI 0.991-0.999), LTB4 (adjusted OR 1.003, 95% CI 1.001-1.005), ΔLTB4 (adjusted OR 1.004, 95% CI 1.002-1.006), and post-EVT LXA4/LTB4 (adjusted OR 0.023, 95% CI 0.001-0.433) and RvD1/LTB4 (adjusted OR 0.196, 95% CI 0.057-0.682) ratios independently predicted END, and post-EVT LXA4 levels (adjusted OR 0.995, 95% CI 0.992-0.999), ΔLXA4 levels (adjusted OR 0.996, 95% CI 0.993-0.999), and post-EVT LXA4/LTB4 ratio (adjusted OR 0.285, 95% CI 0.096-0.845) independently predicted unfavorable 90-day functional outcome. These were validated using receiver operating characteristic curve analyses.ConclusionsPlasma lipid mediators measured 24 hrs post-EVT were independent predictors for early and long-term outcomes. Further studies are needed to determine their causal-effect relationship, and whether the imbalance between anti-inflammatory/pro-resolving and pro-inflammatory lipid mediators could be a potential adjunct therapeutic target.

Dataset Information

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Introduction

Materials and methods

Results

Discussion

Systematic review registration

Publications

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

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