Aristeidis Katsanos1, Guillaume Turc2,3,4,5, Marios Psychogios6, Johannes Kaesmacher7, Lina Palaiodimou8, Maria Ioanna Stefanou8, George Magoufis9, Ashkan Shoamanesh10, Marios Themistocleous11, Simona Sacco12, Jens Fiehler13, Jan Gralla7, Daniel Strbian14, Andrei V Alexandrov15, Urs Fischer16, Georgios Tsivgoulis8,15. 1. Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, ON, Canada Katsanosar.katsanos@gmail.com. 2. Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France. 3. Université de Paris, Paris, France. 4. INSERM U1266, Paris, France. 5. FHU Neurovasc, Paris, France. 6. Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland. 7. Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital University Hospital Bern, Bern, Switzerland. 8. Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. 9. Stroke Unit, Metropolitan Hospital, Piraeus, Greece. 10. Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, ON, Canada. 11. Department of Neurosurgery, Pediatric Hospital of Athens, Agia Sophia, Athens, Greece. 12. Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy. 13. Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 14. Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland. 15. Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA. 16. Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Switzerland.
Abstract
OBJECTIVE: To provide a critical appraisal on the evidence from randomized-controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by intravenous thrombolysis (bridging therapy, BT) for patients with acute large vessel occlusion (LVO). METHODS: Eligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (95%CI) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0-2 at 3 months. RESULTS: We included 3 studies comprising 1092 patients. No difference between dEVT and BT groups was detected for the outcomes of mRS 0-2 (OR=1.08,95%CI:0.85-1.38; adjusted OR=1.11, 95%CI:0.76-1.63), mRS 0-1 (OR=1.10, 95%CI:0.84-1.43; adjusted OR=1.16, 95%CI:0.84-1.61) and functional improvement at 3 months (common OR=1.08, 95%CI:0.88-1.34; adjusted common OR=1.09, 95%CI:0.86-1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization prior to the endovascular procedure compared to BT (OR=0.37, 95%CI:0.18-0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR=0.67, 95%CI:0.49-0.92), however, without significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events or procedural complications between the two groups were uncovered. CONCLUSIONS: We detected no differences in functional outcomes of IV thrombolysis eligible patients with an acute LVO receiving dEVT compared to BT. Since uncertainty for most endpoints remains large and the available data is not able to exclude the possibility of overall benefit or harm, further RCTs are needed.
OBJECTIVE: To provide a critical appraisal on the evidence from randomized-controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by intravenous thrombolysis (bridging therapy, BT) for patients with acute large vessel occlusion (LVO). METHODS: Eligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (95%CI) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0-2 at 3 months. RESULTS: We included 3 studies comprising 1092 patients. No difference between dEVT and BT groups was detected for the outcomes of mRS 0-2 (OR=1.08,95%CI:0.85-1.38; adjusted OR=1.11, 95%CI:0.76-1.63), mRS 0-1 (OR=1.10, 95%CI:0.84-1.43; adjusted OR=1.16, 95%CI:0.84-1.61) and functional improvement at 3 months (common OR=1.08, 95%CI:0.88-1.34; adjusted common OR=1.09, 95%CI:0.86-1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization prior to the endovascular procedure compared to BT (OR=0.37, 95%CI:0.18-0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR=0.67, 95%CI:0.49-0.92), however, without significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events or procedural complications between the two groups were uncovered. CONCLUSIONS: We detected no differences in functional outcomes of IV thrombolysis eligible patients with an acute LVO receiving dEVT compared to BT. Since uncertainty for most endpoints remains large and the available data is not able to exclude the possibility of overall benefit or harm, further RCTs are needed.
Authors: Guillaume Turc; Georgios Tsivgoulis; Heinrich J Audebert; Hieronymus Boogaarts; Pervinder Bhogal; Gian Marco De Marchis; Ana Catarina Fonseca; Pooja Khatri; Mikaël Mazighi; Natalia Pérez de la Ossa; Peter D Schellinger; Daniel Strbian; Danilo Toni; Philip White; William Whiteley; Andrea Zini; Wim van Zwam; Jens Fiehler Journal: Eur Stroke J Date: 2022-02-17
Authors: Alex Brehm; Ioannis Tsogkas; Johanna M Ospel; Christian Appenzeller-Herzog; Junya Aoki; Kazumi Kimura; Johannes A R Pfaff; Markus A Möhlenbruch; Manuel Requena; Marc J Ribo; Amrou Sarraj; Alejandro M Spiotta; Peter Sporns; Marios-Nikos Psychogios Journal: Ther Adv Neurol Disord Date: 2022-03-02 Impact factor: 6.570