title: Endovascular vs medical management of acute ischemic stroke.
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.
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville. chenjared@gmail.com.
authors.forename: Ching-Jen
authors.initials: CJ
authors.lastname: Chen
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: Prachi
authors.initials: P
authors.lastname: Mehndiratta
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: R Webster
authors.initials: RW
authors.lastname: Crowley
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Liu
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Southerland
authors.affiliation: From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S., B.B.W.), University of Virginia Health System, Charlottesville.
authors.forename: Bradford B
authors.initials: BB
authors.lastname: Worrall
mesh_terms: D002545:Brain Ischemia / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D019468:Disease Management; D057510:Endovascular Procedures / Q000379:methods*; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D020521:Stroke / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D017131:Thrombectomy; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator