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JAMA Neurol. 2019 Apr 8. doi: 10.1001/jamaneurol.2019.0525. [Epub ahead of print]

Endovascular Thrombectomy as a Means to Improve Survival in Acute Ischemic Stroke: A Meta-analysis.

Author information

1
Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
2
Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
3
Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
4
Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany.

Abstract

Importance:

Although endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality.

Objective:

To identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis.

Data Sources:

All randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines.

Study Selection:

Ten American Stroke Association/American Heart Association guideline-relevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT.

Data Extraction and Synthesis:

Data were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs.

Main Outcomes and Measures:

Risk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward).

Results:

In 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98; P = .03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01; P = .06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40; P = .38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72; P = .65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials.

Conclusions and Relevance:

This meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.

PMID:
30958530
PMCID:
PMC6583698
[Available on 2020-04-08]
DOI:
10.1001/jamaneurol.2019.0525

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