Michele Romoli1,2, Maria Giulia Mosconi3, Patrizia Pierini3, Andrea Alberti3, Michele Venti3, Valeria Caso4, Simone Vidale5, Enrico Maria Lotti5, Marco Longoni4, Paolo Calabresi6,7, Georgios Tsivgoulis8,9, Maurizio Paciaroni3. 1. Neurology Clinic, University of Perugia-S. Maria della Misericordia Hospital, Perugia, Italy. michele.romoli@studenti.unipg.it. 2. Neurology Unit, Rimini "Infermi" Hospital-AUSL Romagna, Viale Settembrini 2, 47923, Rimini, Italy. michele.romoli@studenti.unipg.it. 3. Stroke Unit and Division of Cardiovascular Medicine, University of Perugia-S. Maria della Misericordia Hospital, Perugia, Italy. 4. Neurology Unit, "M. Bufalini" Hospital-AUSL Romagna, Cesena, Italy. 5. Neurology Unit, Rimini "Infermi" Hospital-AUSL Romagna, Viale Settembrini 2, 47923, Rimini, Italy. 6. Institute of Neurology, Catholic University of Sacred Heart, Roma, Italy. 7. Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy. 8. Second Department of Neurology, "Attikon" Hospital School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. 9. Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
Abstract
INTRODUCTION: Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment. METHODS: Systematic review followed predefined protocol (Open-Science-Framework osf.io/bfykj ). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment. RESULTS: Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (n = 450) did not differ for favorable outcome and mortality compared to EVT (n = 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2-0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3-3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1-3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1-4.4) but similar mortality rates. CONCLUSIONS: Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.
INTRODUCTION: Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment. METHODS: Systematic review followed predefined protocol (Open-Science-Framework osf.io/bfykj ). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment. RESULTS: Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (n = 450) did not differ for favorable outcome and mortality compared to EVT (n = 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2-0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3-3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1-3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1-4.4) but similar mortality rates. CONCLUSIONS: Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.
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