A meta-analysis published in the Journal of the American Medical Association (JAMA) has found that endovascular intervention compared to standard medical care can be associated with improved functional outcomes and higher rates of functional independence at 90 days.
The paper, which analysed randomised clinical trials for the treatment of acute ischaemic stroke, found no significant difference in symptomatic intracranial haemorrhage or all-cause mortality.
Saleh A Almenawer, of McMaster University, Hamilton, Ontario, Canada, and colleagues conducted a meta-analysis that included data from eight trials involving 2,423 patients with acute ischaemic stroke (average age; 67 years; 47% women), including 1,313 who underwent endovascular thrombectomy and 1,110 who received standard medical care with tPA. For this analysis, endovascular therapy was defined as the intra-arterial use of a microcatheter or other device for mechanical thrombectomy, with or without the use of a chemical thrombolytic agent.
The researchers found that endovascular therapy was associated with a significant treatment benefit across measures of functional outcomes. Functional independence at 90 days occurred among 45% of the patients in the endovascular therapy group vs. 32% of the patients in the standard medical care group. Compared with standard medical care, endovascular thrombectomy was associated with significantly higher rates of angiographic revascularisation at 24 hours but no significant difference in rates of symptomatic intracranial haemorrhage (5.7% vs 5.1%) or all-cause mortality at 90 days (218 deaths [16%] vs 201 deaths [18%]).
“Thrombectomy appears to improve functional outcome for selected patients with internal carotid artery or middle cerebral artery main stem thrombus who have limited comorbidities and who are younger than 80 years. For these patients, intravenous recombinant tissue plasminogen activator should be initiated quickly (if the patient has no contraindications) while rapidly preparing for thrombectomy. Perfusion imaging is not essential,” write Joanna M Wardlaw and Martin S Dennis, University of Edinburgh, UK, in an accompanying editorial. “Clinicians should realise that thrombectomy is not necessarily safer than standard medical care, with similar risks of symptomatic intracranial haemorrhage and all-cause mortality.”
Wardlaw and Dennis add, “Additional trials are needed to systematically study the relationship of patient-, disease-, and treatment-related variables with outcomes following mechanical thrombectomy, and to identify the ideal patient to undergo endovascular therapy.”