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Mechanical thrombectomy for emergent large vessel occlusion: a critical appraisal of recent randomized controlled clinical trials.

Tsivgoulis G, Safouris A, Katsanos AH, Arthur AS, Alexandrov AV - Brain Behav (2016)

Bottom Line: MT was performed with stent retrievers, aspiration techniques, or a combination of these endovascular approaches.We applied meta-analytical methodology to evaluate the pooled effect of MT on recanalization/reperfusion, sICH, functional independence (modified Rankin scale score of 0-2) and 3-month mortality rates in comparison to best medical therapy (BMT).For every six ELVO patients treated with MT three more will achieve complete recanalization at 24 h following symptom onset and one more will be functionally independent at 3 months in comparison to BMT.

View Article: PubMed Central - PubMed

Affiliation: Department of NeurologyUniversity of Tennessee Health Science CenterMemphisTennessee; Second Department of Neurology"Attikon University Hospital"School of MedicineUniversity of AthensAthensGreece; International Clinical Research CenterSt. Anne's University Hospital in BrnoBrnoCzech Republic.

ABSTRACT

Background and purpose: After numerous attempts to prove efficacy for endovascular treatment of ischemic stroke, a series of recent randomized controlled clinical trials (RCTs) established fast mechanical thrombectomy (MT) as a safe and effective novel treatment for emergent large vessel occlusion (ELVO) in the anterior cerebral circulation.

Methods: We reviewed five recent RCTs that evaluated the safety and efficacy of MT in ELVO patients and captured available information on recanalization/reperfusion, symptomatic intracranial hemorrhage (sICH), clinical outcome, and mortality. MT was performed with stent retrievers, aspiration techniques, or a combination of these endovascular approaches. We applied meta-analytical methodology to evaluate the pooled effect of MT on recanalization/reperfusion, sICH, functional independence (modified Rankin scale score of 0-2) and 3-month mortality rates in comparison to best medical therapy (BMT).

Results: MT was associated with increased likelihood of complete recanalization/reperfusion (RR: 2.22; 95%CI: 1.89-2.62; P < 0.00001) and 3-month functional independence (RR: 1.72; 95%CI: 1.48-1.99; P < 0.00001) without any heterogeneity across trials (I (2) = 0%). The absolute benefit increase in MT for complete recanalization/reperfusion and functional independence was 44 (NNT = 2) and 16 (NNT = 6), respectively. MT was not associated with increased risk of 3-month mortality (15% with MT vs. 19% with BMT) and sICH (4.6% with MT vs. 4.3% with BMT), while small heterogeneity was detected across the included trials (I (2) < 25%).

Conclusions: MT is a safe and highly effective treatment for patients with ELVO in the anterior circulation. For every six ELVO patients treated with MT three more will achieve complete recanalization at 24 h following symptom onset and one more will be functionally independent at 3 months in comparison to BMT.

No MeSH data available.


Related in: MedlinePlus

Association of mechanical thrombectomy (vs. best medical therapy) with the likelihood of symptomatic intracranial hemorrhage (sICH) across different RCTs.
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brb3418-fig-0003: Association of mechanical thrombectomy (vs. best medical therapy) with the likelihood of symptomatic intracranial hemorrhage (sICH) across different RCTs.

Mentions: High complete recanalization rates were documented at the end of the endovascular procedures in all RCTs ranging from 59% in MR CLEAN to 88% in SWIFT PRIME, while follow‐up neuroimaging studies at 24–27 h reported similar rates for persistent recanalization/reperfusion (Table 3). The pooled complete recanalization rate at the end of endovascular procedure was 74% (95% CI: 63%–83%; Fig. 1), but there was evidence of substantial heterogeneity across the five RCTs (I2 = 85%, P for Cohran Q < 0.001). Compared to BMT, MT was associated with an increased probability of complete recanalization/reperfusion at 24–27 h from symptom onset (RR: 2.22; 95% CI: 1.89–2.62; P < 0.00001; Fig. 2) and there was no evidence of heterogeneity across trials (I2 = 0%). The absolute benefit increase was 44% with MT and that corresponded to a number needed to treat (NNT) of 2. Increased complete recanalization rates resulted in reduced infarction volume at 24–27 h after treatment, a difference that was statistically significant in two of the three trials that provided relative data (Table 4). MT was not associated with an increased risk of sICH (RR: 1.17; 95% CI: 0.66–2.07; P = 0.58; Fig. 3) without any evidence of significant heterogeneity across trials (I2 = 5%, P for Cohran Q = 0.38). More specifically, the pooled sICH rates were 4.6% and 4.3% in the MT and BMT groups, respectively. Compared to BMT, MT was associated with an increased likelihood of functional independence (modified Rankin scale score of 0–2) at 3 months (RR: 1.72; 95% CI: 1.48–1.99; P < 0.00001; Fig. 4) and there was no evidence of heterogeneity across trials (I2 = 0%). The absolute benefit increase was 16% with MT (42% vs. 26% with BMT) and that corresponded to an NNT of 6.


Mechanical thrombectomy for emergent large vessel occlusion: a critical appraisal of recent randomized controlled clinical trials.

Tsivgoulis G, Safouris A, Katsanos AH, Arthur AS, Alexandrov AV - Brain Behav (2016)

Association of mechanical thrombectomy (vs. best medical therapy) with the likelihood of symptomatic intracranial hemorrhage (sICH) across different RCTs.
© Copyright Policy - creativeCommonsBy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4834930&req=5

brb3418-fig-0003: Association of mechanical thrombectomy (vs. best medical therapy) with the likelihood of symptomatic intracranial hemorrhage (sICH) across different RCTs.
Mentions: High complete recanalization rates were documented at the end of the endovascular procedures in all RCTs ranging from 59% in MR CLEAN to 88% in SWIFT PRIME, while follow‐up neuroimaging studies at 24–27 h reported similar rates for persistent recanalization/reperfusion (Table 3). The pooled complete recanalization rate at the end of endovascular procedure was 74% (95% CI: 63%–83%; Fig. 1), but there was evidence of substantial heterogeneity across the five RCTs (I2 = 85%, P for Cohran Q < 0.001). Compared to BMT, MT was associated with an increased probability of complete recanalization/reperfusion at 24–27 h from symptom onset (RR: 2.22; 95% CI: 1.89–2.62; P < 0.00001; Fig. 2) and there was no evidence of heterogeneity across trials (I2 = 0%). The absolute benefit increase was 44% with MT and that corresponded to a number needed to treat (NNT) of 2. Increased complete recanalization rates resulted in reduced infarction volume at 24–27 h after treatment, a difference that was statistically significant in two of the three trials that provided relative data (Table 4). MT was not associated with an increased risk of sICH (RR: 1.17; 95% CI: 0.66–2.07; P = 0.58; Fig. 3) without any evidence of significant heterogeneity across trials (I2 = 5%, P for Cohran Q = 0.38). More specifically, the pooled sICH rates were 4.6% and 4.3% in the MT and BMT groups, respectively. Compared to BMT, MT was associated with an increased likelihood of functional independence (modified Rankin scale score of 0–2) at 3 months (RR: 1.72; 95% CI: 1.48–1.99; P < 0.00001; Fig. 4) and there was no evidence of heterogeneity across trials (I2 = 0%). The absolute benefit increase was 16% with MT (42% vs. 26% with BMT) and that corresponded to an NNT of 6.

Bottom Line: MT was performed with stent retrievers, aspiration techniques, or a combination of these endovascular approaches.We applied meta-analytical methodology to evaluate the pooled effect of MT on recanalization/reperfusion, sICH, functional independence (modified Rankin scale score of 0-2) and 3-month mortality rates in comparison to best medical therapy (BMT).For every six ELVO patients treated with MT three more will achieve complete recanalization at 24 h following symptom onset and one more will be functionally independent at 3 months in comparison to BMT.

View Article: PubMed Central - PubMed

Affiliation: Department of NeurologyUniversity of Tennessee Health Science CenterMemphisTennessee; Second Department of Neurology"Attikon University Hospital"School of MedicineUniversity of AthensAthensGreece; International Clinical Research CenterSt. Anne's University Hospital in BrnoBrnoCzech Republic.

ABSTRACT

Background and purpose: After numerous attempts to prove efficacy for endovascular treatment of ischemic stroke, a series of recent randomized controlled clinical trials (RCTs) established fast mechanical thrombectomy (MT) as a safe and effective novel treatment for emergent large vessel occlusion (ELVO) in the anterior cerebral circulation.

Methods: We reviewed five recent RCTs that evaluated the safety and efficacy of MT in ELVO patients and captured available information on recanalization/reperfusion, symptomatic intracranial hemorrhage (sICH), clinical outcome, and mortality. MT was performed with stent retrievers, aspiration techniques, or a combination of these endovascular approaches. We applied meta-analytical methodology to evaluate the pooled effect of MT on recanalization/reperfusion, sICH, functional independence (modified Rankin scale score of 0-2) and 3-month mortality rates in comparison to best medical therapy (BMT).

Results: MT was associated with increased likelihood of complete recanalization/reperfusion (RR: 2.22; 95%CI: 1.89-2.62; P < 0.00001) and 3-month functional independence (RR: 1.72; 95%CI: 1.48-1.99; P < 0.00001) without any heterogeneity across trials (I (2) = 0%). The absolute benefit increase in MT for complete recanalization/reperfusion and functional independence was 44 (NNT = 2) and 16 (NNT = 6), respectively. MT was not associated with increased risk of 3-month mortality (15% with MT vs. 19% with BMT) and sICH (4.6% with MT vs. 4.3% with BMT), while small heterogeneity was detected across the included trials (I (2) < 25%).

Conclusions: MT is a safe and highly effective treatment for patients with ELVO in the anterior circulation. For every six ELVO patients treated with MT three more will achieve complete recanalization at 24 h following symptom onset and one more will be functionally independent at 3 months in comparison to BMT.

No MeSH data available.


Related in: MedlinePlus