Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis.
OBJECTIVE
To evaluate the efficacy and safety of endovascular treatment, particularly adjunctive intra-arterial mechanical thrombectomy, in patients with ischaemic stroke.


METHODS
Systematic review and meta-analysis.


METHODS
Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, SciELO, LILACS, and clinical trial registries from inception to December 2015. Reference lists were crosschecked.


METHODS
Randomised controlled trials in adults aged 18 or more with ischaemic stroke comparing endovascular treatment, including thrombectomy, with medical care alone, including intravenous recombinant tissue plasminogen activator (rt-PA). Trial endpoints were functional outcome (modified Rankin scale scores of ≤2) and mortality at 90 days after onset of symptoms. No language or time restrictions applied.


RESULTS
10 randomised controlled trials (n=2925) were included. In pooled analysis endovascular treatment, including thrombectomy, was associated with a higher proportion of patients experiencing good (modified Rankin scale scores ≤2) and excellent (scores ≤1) outcomes 90 days after stroke, without differences in mortality or rates for symptomatic intracranial haemorrhage, compared with patients randomised to medical care alone, including intravenous rt-PA. Heterogeneity was high among studies. The more recent studies (seven randomised controlled trials, published or presented in 2015) proved better suited to evaluate the effect of adjunctive intra-arterial mechanical thrombectomy on its index disease owing to more accurate patient selection, intravenous rt-PA being administered at a higher rate and earlier, and the use of more efficient thrombectomy devices. In most of these studies, more than 86% of the patients were treated with stent retrievers, and rates of recanalisation were higher (>58%) than previously reported. Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies. All trials were open label. Risk of bias was moderate across studies. The full results of two trials are yet to be published.


CONCLUSIONS
Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.


BACKGROUND
PROSPERO CRD42015019340.
Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal filipebrodrigues@gmail.com.
Filipe Brogueira
FB
Rodrigues
Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal.
Joana Briosa
JB
Neves
Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.
Daniel
D
Caldeira
Department of Neurosciences, Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal.
José M
JM
Ferro
Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Department of Neurosciences, Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal.
Joaquim J
JJ
Ferreira
Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Portugal Portuguese Collaborating Center of the IberoAmerican Cochrane Network, Faculty of Medicine, University of Lisbon, Portugal.
João
J
Costa
D061605:Administration, Intravenous; D002545:Brain Ischemia / Q000150:complications / Q000628:therapy*; D017128:Embolectomy / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000453:epidemiology; D061185:Mechanical Thrombolysis / Q000379:methods*; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000628:therapy*; D017131:Thrombectomy / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator