Added Benefit of Stent Retriever Technology for Acute Ischemic Stroke: A Pooled Analysis of the NINDS tPA, SWIFT, and STAR Trials.
BACKGROUND
Endovascular treatment is increasingly being used in acute stroke care. However, although stent retrievers show improved flow restoration rates, their clinical benefits have been uncertain.


OBJECTIVE
To assess the incremental effect of using stent retrievers compared with intravenous tissue plasminogen activator (IV tPA; alteplase) alone or placebo/control.


METHODS
We conducted a pooled analysis of 4 studies using stent retrievers (Solitaire), IV tPA, or placebo/control. We applied the ischemic stroke risk score (www.sorcan.ca/iscore) to each participant to adjust for differences in baseline characteristics. We used a shift analysis to account for the potential benefits across the entire modified Rankin scale score at 90 days, adjusting for time-to-treatment, baseline Alberta Stroke Program Early CT score, and ischemic stroke risk score.


RESULTS
Of the 915 participants in this analysis, 312 (34.1%) patients received placebo, 312 (34.1%) received tPA alone, 131 (14.4%) received stent retrievers alone, and 160 (17.5) received combined therapy (IV tPA plus stent retrievers). The shift analysis revealed that more patients remained independent at 90 days if receiving stent retrievers alone (number needed to treat 3.5) or combined with tPA (number needed to treat 3.1) compared with tPA alone. After adjustment, participants receiving stent retrievers alone (odds ratio, 2.95; 95% confidence interval, 1.48-5.89) or combined with tPA (odds ratio, 4.45; 95% confidence interval, 2.40-8.27) were more likely to be independent at 90 days compared with tPA alone.


CONCLUSIONS
Patients with acute ischemic stroke who received IV tPA or revascularization therapies had a higher likelihood of achieving independence at 3 months. Stent retriever technology combined with tPA was associated with the greatest benefit compared with placebo, tPA alone, or endovascular therapy alone.
*Stroke Outcomes Research Center, Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; ‡Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; §Applied Health Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; ¶Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada; ‖Professor of Neurosurgery and Radiology, University at Buffalo, State University of New York, Buffalo, New York; #Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina; **Dell Medical School, University of Texas, Austin, Texas.
Gustavo
G
Saposnik
Gerald
G
Lebovic
Andrew
A
Demchuk
Elad I
EI
Levy
Bruce
B
Ovbiagele
Mayank
M
Goyal
S Claiborne
SC
Johnston
D061605:Administration, Intravenous; D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy / Q000628:therapy*; D003131:Combined Modality Therapy; D057510:Endovascular Procedures; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D055825:National Institute of Neurological Disorders and Stroke (U.S.); D015607:Stents; D020521:Stroke / Q000188:drug therapy / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D016896:Treatment Outcome; D014481:United States
D005343:Fibrinolytic Agents