Mechanical thrombectomy for emergent large vessel occlusion: a critical appraisal of recent randomized controlled clinical trials.
After numerous attempts to prove efficacy for endovascular treatment of ischemic stroke, a series of recent randomized controlled clinical trials (RCTs) established fast mechanical thrombectomy (MT) as a safe and effective novel treatment for emergent large vessel occlusion (ELVO) in the anterior cerebral circulation.



We reviewed five recent RCTs that evaluated the safety and efficacy of MT in ELVO patients and captured available information on recanalization/reperfusion, symptomatic intracranial hemorrhage (sICH), clinical outcome, and mortality. MT was performed with stent retrievers, aspiration techniques, or a combination of these endovascular approaches. We applied meta-analytical methodology to evaluate the pooled effect of MT on recanalization/reperfusion, sICH, functional independence (modified Rankin scale score of 0-2) and 3-month mortality rates in comparison to best medical therapy (BMT).



MT was associated with increased likelihood of complete recanalization/reperfusion (RR: 2.22; 95%CI: 1.89-2.62; P < 0.00001) and 3-month functional independence (RR: 1.72; 95%CI: 1.48-1.99; P < 0.00001) without any heterogeneity across trials (I (2) = 0%). The absolute benefit increase in MT for complete recanalization/reperfusion and functional independence was 44 (NNT = 2) and 16 (NNT = 6), respectively. MT was not associated with increased risk of 3-month mortality (15% with MT vs. 19% with BMT) and sICH (4.6% with MT vs. 4.3% with BMT), while small heterogeneity was detected across the included trials (I (2) < 25%).



MT is a safe and highly effective treatment for patients with ELVO in the anterior circulation. For every six ELVO patients treated with MT three more will achieve complete recanalization at 24 h following symptom onset and one more will be functionally independent at 3 months in comparison to BMT.
Department of Neurology University of Tennessee Health Science Center Memphis Tennessee; Second Department of Neurology" Attikon University Hospital"School of Medicine University of Athens Athens Greece; International Clinical Research Center St. Anne's University Hospital in Brno Brno Czech Republic.
Georgios
G
Tsivgoulis
Second Department of Neurology" Attikon University Hospital"School of Medicine University of Athens Athens Greece; Stroke Unit Department of Neurology Brugmann University Hospital Brussels Belgium; Stroke Unit Metropolitan Hospital Athens Greece.
Apostolos
A
Safouris
Second Department of Neurology "Attikon University Hospital" School of Medicine University of Athens Athens Greece.
Aristeidis H
AH
Katsanos
Department of Neurology University of Tennessee Health Science Center Memphis Tennessee; Department of Neurosurgery Semmes-Murphey Neurologic and Spine Institute University of Tennessee Health Science Center Memphis Tennessee.
Adam S
AS
Arthur
Department of Neurology University of Tennessee Health Science Center Memphis Tennessee.
Andrei V
AV
Alexandrov
D002545:Brain Ischemia / Q000628:therapy*; D006801:Humans; D061185:Mechanical Thrombolysis / Q000009:adverse effects; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000628:therapy*
Endovascular treatment; intravenous thrombolysis; ischemic stroke; recanalization; thrombectomy