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Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis.

Rodrigues FB, Neves JB, Caldeira D, Ferro JM, Ferreira JJ, Costa J - BMJ (2016)

Bottom Line: Systematic review and meta-analysis.Heterogeneity was high among studies.Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies.

View Article: PubMed Central - PubMed

Affiliation: Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal filipebrodrigues@gmail.com.

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Fig 3 Forest plot for a good functional outcome (modified Rankin scale core ≤2) at 90 days, including subgroup analysis by year of study publication. AIMT=adjunctive intra-arterial mechanical thrombectomy
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f3: Fig 3 Forest plot for a good functional outcome (modified Rankin scale core ≤2) at 90 days, including subgroup analysis by year of study publication. AIMT=adjunctive intra-arterial mechanical thrombectomy

Mentions: Overall, 1129 out of 2907 patients (38.8%) achieved a good functional outcome at 90 days. Patients receiving endovascular treatment had a higher chance of achieving a good outcome (risk ratio 1.37, 95% confidence interval 1.14 to 1.64; fig 3), with an increase of 123 patients (95% confidence interval 46 to 212 patients) attaining a good outcome for each 1000 additional patients receiving endovascular treatment compared with medical care alone. Considerable statistical heterogeneity (I2=69%, P=0.0006) was present for overall pooled results of studies, but not for pooled results of studies published in 2013 (I2=0%; P=0.62) and in 2015 (I2=0%; P=0.43), which further support our a priori hypothesis that heterogeneity would exist between the results of trials done in 2013 and those done in 2015 owing to inequalities in study design, including patient populations and interventions. Indeed, the results for efficacy outcomes were significantly different (P<0.001) between these two subgroups of trials. No differences were found in the proportion of patients reaching modified Rankin scale scores of ≤2 (fig 3) or ≤1 (supplementary figure S1) among 2013 trials. In contrast, the pooled risk ratio for 2015 trials was 1.56 (95% confidence interval 1.38 to 1.75), representing an increase of 167 patients (95% confidence interval 113 to 223 patients) attaining a good outcome (modified Rankin scale score ≤2) for each 1000 additional patients receiving endovascular treatment compared with medical care alone. Additionally, the pooled risk ratio for 2015 trials for a modified Rankin scale score of ≤1 (supplementary figure S1) was 2.03 (95% confidence interval 1.62 to 2.53; I2=0, P=0.99), representing an increase of 131 patients (79 to 195 patients) attaining an excellent outcome for each 1000 additional patients receiving endovascular treatment compared with medical care alone. Data on outcomes for THRACE and THERAPY are not yet completely published. Sensitivity analysis excluding these studies from pooled risk ratio for 2015 trials yielded similar results: modified Rankin scale scores ≤2 (risk ratio 1.73, 95% confidence interval 1.49 to 2.01; I2=0, P=0.97) and ≤1 (2.04, 1.62 to 2.58; I2=0, P=0.99). Further sensitivity analysis excluding trials with low rates of patients treated with intravenous rt-PA in the control arm (MR RESCUE) or with low rates of adjunctive intra-arterial mechanical thrombectomy in the endovascular treatment arm (IMS III and SYNTHESIS) also yielded similar results for all efficacy outcomes; all these trials were published in 2013.


Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis.

Rodrigues FB, Neves JB, Caldeira D, Ferro JM, Ferreira JJ, Costa J - BMJ (2016)

Fig 3 Forest plot for a good functional outcome (modified Rankin scale core ≤2) at 90 days, including subgroup analysis by year of study publication. AIMT=adjunctive intra-arterial mechanical thrombectomy
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4834754&req=5

f3: Fig 3 Forest plot for a good functional outcome (modified Rankin scale core ≤2) at 90 days, including subgroup analysis by year of study publication. AIMT=adjunctive intra-arterial mechanical thrombectomy
Mentions: Overall, 1129 out of 2907 patients (38.8%) achieved a good functional outcome at 90 days. Patients receiving endovascular treatment had a higher chance of achieving a good outcome (risk ratio 1.37, 95% confidence interval 1.14 to 1.64; fig 3), with an increase of 123 patients (95% confidence interval 46 to 212 patients) attaining a good outcome for each 1000 additional patients receiving endovascular treatment compared with medical care alone. Considerable statistical heterogeneity (I2=69%, P=0.0006) was present for overall pooled results of studies, but not for pooled results of studies published in 2013 (I2=0%; P=0.62) and in 2015 (I2=0%; P=0.43), which further support our a priori hypothesis that heterogeneity would exist between the results of trials done in 2013 and those done in 2015 owing to inequalities in study design, including patient populations and interventions. Indeed, the results for efficacy outcomes were significantly different (P<0.001) between these two subgroups of trials. No differences were found in the proportion of patients reaching modified Rankin scale scores of ≤2 (fig 3) or ≤1 (supplementary figure S1) among 2013 trials. In contrast, the pooled risk ratio for 2015 trials was 1.56 (95% confidence interval 1.38 to 1.75), representing an increase of 167 patients (95% confidence interval 113 to 223 patients) attaining a good outcome (modified Rankin scale score ≤2) for each 1000 additional patients receiving endovascular treatment compared with medical care alone. Additionally, the pooled risk ratio for 2015 trials for a modified Rankin scale score of ≤1 (supplementary figure S1) was 2.03 (95% confidence interval 1.62 to 2.53; I2=0, P=0.99), representing an increase of 131 patients (79 to 195 patients) attaining an excellent outcome for each 1000 additional patients receiving endovascular treatment compared with medical care alone. Data on outcomes for THRACE and THERAPY are not yet completely published. Sensitivity analysis excluding these studies from pooled risk ratio for 2015 trials yielded similar results: modified Rankin scale scores ≤2 (risk ratio 1.73, 95% confidence interval 1.49 to 2.01; I2=0, P=0.97) and ≤1 (2.04, 1.62 to 2.58; I2=0, P=0.99). Further sensitivity analysis excluding trials with low rates of patients treated with intravenous rt-PA in the control arm (MR RESCUE) or with low rates of adjunctive intra-arterial mechanical thrombectomy in the endovascular treatment arm (IMS III and SYNTHESIS) also yielded similar results for all efficacy outcomes; all these trials were published in 2013.

Bottom Line: Systematic review and meta-analysis.Heterogeneity was high among studies.Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies.

View Article: PubMed Central - PubMed

Affiliation: Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal filipebrodrigues@gmail.com.

Show MeSH
Related in: MedlinePlus