Systematic Review and Pooled Analyses of Recent Neurointerventional Randomized Controlled Trials: Setting a New Standard of Care for Acute Ischemic Stroke Treatment after 20 Years.
BACKGROUND
Recent advances in the treatment of ischemic stroke have focused on revascularization and led to better clinical and functional outcomes. A systematic review and pooled analyses of 6 recent multicentered prospective randomized controlled trials (MPRCT) were performed to compare intravenous tissue plasminogen activator (IV tPA) and endovascular therapy (intervention) with IV tPA alone (control) for anterior circulation ischemic stroke (AIS) secondary to large vessel occlusion (LVO).


OBJECTIVE
Six MPRCTs (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, REVASCAT and THERAPY) incorporating image-based LVO AIS were selected for assessing the following: (1) prespecified primary clinical outcomes of AIS patients in intervention and control arms: good outcomes were defined by a modified Rankin Scale score of 0-2 at 90 days; (2) secondary clinical outcomes were: (a) revascularization rates [favorable outcomes defined as modified Thrombolysis in Cerebral Infarction scale (mTICI) score of 2b/3]; (b) symptomatic intracranial hemorrhage (sICH) rates and mortality; (c) derivation of number needed to harm (NNH), number needed to treat (NNT), and relative percent difference (RPD) between intervention and control groups, and (d) random effects model to determine overall significance (forest and funnel plots).


RESULTS
A total of 1,386 patients were included. Good outcomes at 90 days were seen in 46% of patients in the intervention (p < 0.00001) and in 27% of patients in the control groups (p < 0.00002). An mTICI score of 2b/3 was achieved in 70.2% of patients in the intervention arm. The sICH and mortality in the intervention arm compared with the control arm were 4.7 and 14.3% versus 7.9 and 17.8%, respectively. The NNT and NNH in the intervention and control groups were 5.3 and 9.1, respectively. Patients in the intervention arm had a 50.1% (RPD) better chance of achieving a good 90-day outcome as compared to controls.


CONCLUSIONS
Endovascular therapy combined with IV tPA (in appropriately selected patients) for LVO-related AIS is superior to IV tPA alone. These results support establishing an endovascular therapy in addition to IV tPA as the standard of care for AIS secondary to LVO.
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Mohammed
M
Hussain
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Mohammad
M
Moussavi
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Daniel
D
Korya
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Siddhart
S
Mehta
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Jaskiran
J
Brar
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Harina
H
Chahal
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Ihtesham
I
Qureshi
Department of Neurology, Hartford Hospital, University of Connecticut, Hartford, Conn., USA.
Tapan
T
Mehta
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Javaad
J
Ahmad
Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA.
Osama O
OO
Zaidat
Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA.
Jawad F
JF
Kirmani
Embolectomy; Endovascular therapy; Intra-arterial intervention; Ischemic stroke; Neurointervention; Pooled analysis; Randomized controlled trials