Kévin Premat1, Agnes Dechartres2, Stéphanie Lenck3, Eimad Shotar3, Raphaël Le Bouc4, Vincent Degos5, Nader Sourour3, Sonia Alamowitch6, Yves Samson4, Frédéric Clarençon3. 1. Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital, F75013, Paris, France. kevin.premat@aphp.fr. 2. Departement of Biostatistics, Sorbonne University, INSERM, Pierre Louis Institute of Epidemiology and Public Health, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Public Health and Medical Information, F75013, Paris, France. 3. Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital, F75013, Paris, France. 4. Departement of Vascular Neurology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, F75013, Paris, France. 5. Department of Anesthesiology and Critical Care, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, F75013, Paris, France. 6. Departement of Vascular Neurology, Sorbonne University, AP-HP, Saint Antoine Hospital, F75012, Paris, France.
Abstract
PURPOSE: Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization. METHODS: We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and ClinicalTrials.gov from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0-2, mortality and symptomatic intracranial hemorrhage (SICH). RESULTS: Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio [OR], 2.87 [95% confidence interval (95% CI), 1.77-4.66]; p < 0.001; I2, 0%) and lower mortality (OR, 0.39 [0.16-0.93]; p = 0.03; I2, 43%), whereas SICH rates did not significantly differ (OR, 0.68 [0.37-1.27]; p = 0.23; I2, 0%). CONCLUSION: From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.
PURPOSE: Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization. METHODS: We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and ClinicalTrials.gov from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0-2, mortality and symptomatic intracranial hemorrhage (SICH). RESULTS: Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio [OR], 2.87 [95% confidence interval (95% CI), 1.77-4.66]; p < 0.001; I2, 0%) and lower mortality (OR, 0.39 [0.16-0.93]; p = 0.03; I2, 43%), whereas SICH rates did not significantly differ (OR, 0.68 [0.37-1.27]; p = 0.23; I2, 0%). CONCLUSION: From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.
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