Acute endovascular reperfusion therapy in ischemic stroke: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Randomized controlled trials (RCTs) of endovascular therapy for acute ischemic stroke have had inconsistent results. We evaluated the efficacy and safety of endovascular therapy in published RCTs.


METHODS
We performed a systematic review of RCTs of endovascular therapy with thrombolytic or mechanical reperfusion compared with interventions without endovascular therapy. Primary outcome was the frequency of good functional outcome (modified Rankin scale (mRS) of 0-2 at 90 days) and secondary outcomes were mortality at 90 days and symptomatic intracranial hemorrhage (sICH). Random-effects meta-analysis was performed and the Cochrane risk of bias assessment was used to evaluate quality of evidence.


RESULTS
Ten studies involving 1,612 subjects were included. Endovascular therapy was not significantly associated with good functional outcome (Relative Risk [RR] =1.17; 95% CI, 0.97 to 1.42; p=0.10 and Absolute Risk Difference [ARD] =7%; 95%CI -0.1% to 14%; p=0.05); heterogeneity was moderate among studies (I2=30%). Mortality was unchanged with endovascular therapy (RR=0.92; 95 % CI, 0.75 to 1.13; p=0.45) and there was no difference in sICH (RR=1.20; 95 % CI, 0.79 to 1.82; p=0.39). The quality of evidence was low for all outcomes and the recommendation is weak for the use of endovascular therapy as per GRADE methodology.


CONCLUSIONS
Intra-arterial therapy did not show significant increase in good outcomes and no changes in either mortality or sICH in patients with acute ischemic stroke. We need further RCTs with better design and quality to evaluate the true efficacy of endovascular therapy.
Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, United States of America.
Toshiya
T
Osanai
Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America.
Vinay
V
Pasupuleti
Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, Ohio, United States of America.
Abhishek
A
Deshpande
Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America.
Priyaleela
P
Thota
Unidad de Análisis y Generación de Evidencias en Salud Pública (UNAGESP), Instituto Nacional de Salud, Lima, Peru.
Yuani
Y
Roman
Medical School, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; Health Outcomes and Clinical Epidemiology Section, Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America.
Adrian V
AV
Hernandez
Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, United States of America.
Ken
K
Uchino
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy* / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000188:drug therapy / Q000601:surgery; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D015424:Reperfusion / Q000379:methods; D020521:Stroke / Q000188:drug therapy* / Q000601:surgery*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods; D055815:Young Adult
D005343:Fibrinolytic Agents