title: Functional outcome after primary endovascular therapy or IV thrombolysis alone for stroke. An observational, comparative effectiveness study.
abstract: BACKGROUND
  Among the acute ischemic stroke patients with large vessel occlusions and contraindications for the use of IV thrombolysis, mainly on oral anticoagulation or presenting too late, primary endovascular therapy is often performed as an alternative to the standard therapy even though evidence supporting the use of endovascular reperfusion therapies is not yet established. Using different statistical approaches, we compared the functional independence rates at 3 months among patients undergoing primary endovascular therapy and patients treated only with IV thrombolysis.
  
  
  METHODS
  We used data from a prospective, government-mandated and externally audited registry of reperfusion therapies for ischemic stroke (January 2011 to November 2012). Patients were selected if treated with either IV thrombolysis alone (n = 1,582) or primary endovascular thrombectomy (n = 250). A series of exclusions were made to homogenize the clinical characteristics among the two groups. We then carried out multivariate logistic regression and propensity score matching analyses on the final study sample (n = 1,179) to compare functional independence at 3 months, as measured by the modified Rankin scale scores 0-2, between the two groups.
  
  
  RESULTS
  The unadjusted likelihood of good outcome was poorer among the endovascular group (OR: 0.69; 95% CI: 0.47-1.0). After adjustment, no differences by treatment modality were seen (OR: 1.51; 95% CI: 0.93-2.43 for primary endovascular therapy). Patients undergoing endovascular thrombectomy within 180-270 min (OR: 2.89; 95% CI: 1.17-7.15) and patients with severe strokes (OR: 1.84; 95% CI: 1.02-3.35) did better than their intravenous thrombolysis counterparts. The propensity score-matched analyses with and without adjustment by additional covariates showed that endovascular thrombectomy was as effective as intravenous thrombolysis alone in achieving functional independence (OR for unadjusted propensity score matched: 1.35; 95% CI: 0.9-2.02, OR for adjusted propensity score matched: 1.45; 95% CI: 0.91-2.32).
  
  
  CONCLUSIONS
  This comparative effectiveness study shows that in ischemic stroke patients with contraindications for IV thrombolysis, primary endovascular treatment might be an alternative therapy at least as effective as IV thrombolysis alone. Randomized controlled trials are urgently needed.
authors.affiliation: Stroke Program, Agency for Health Quality and Assessment of Catalonia, Spain.
authors.forename: Sònia
authors.initials: S
authors.lastname: Abilleira
authors.forename: Aida
authors.initials: A
authors.lastname: Ribera
authors.forename: Antonio
authors.initials: A
authors.lastname: Dávalos
authors.forename: Marc
authors.initials: M
authors.lastname: Ribó
authors.forename: Angel
authors.initials: A
authors.lastname: Chamorro
authors.forename: Pere
authors.initials: P
authors.lastname: Cardona
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Molina
authors.forename: Antonio
authors.initials: A
authors.lastname: Martínez-Yélamos
authors.forename: Xabier
authors.initials: X
authors.lastname: Urra
authors.forename: Laura
authors.initials: L
authors.lastname: Dorado
authors.forename: Jaume
authors.initials: J
authors.lastname: Roquer
authors.forename: Joan
authors.initials: J
authors.lastname: Martí-Fàbregas
authors.forename: Lucía
authors.initials: L
authors.lastname: Aja
authors.forename: Alejandro
authors.initials: A
authors.lastname: Tomasello
authors.forename: Carlos
authors.initials: C
authors.lastname: Castaño
authors.forename: Jordi
authors.initials: J
authors.lastname: Blasco
authors.forename: David
authors.initials: D
authors.lastname: Cánovas
authors.forename: Mar
authors.initials: M
authors.lastname: Castellanos
authors.forename: Jerzy
authors.initials: J
authors.lastname: Krupinski
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Guimaraens
authors.forename: Joan
authors.initials: J
authors.lastname: Perendreu
authors.forename: Xavier
authors.initials: X
authors.lastname: Ustrell
authors.forename: Francisco
authors.initials: F
authors.lastname: Purroy
authors.forename: Manuel
authors.initials: M
authors.lastname: Gómez-Choco
authors.forename: Joan Josep
authors.initials: JJ
authors.lastname: Baiges
authors.forename: Dolores
authors.initials: D
authors.lastname: Cocho
authors.forename: Júlia
authors.initials: J
authors.lastname: Saura
authors.forename: Miquel
authors.initials: M
authors.lastname: Gallofré
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator