Journal
VASCULAR PHARMACOLOGY
Volume 150, Issue -, Pages -Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.vph.2023.107177
Keywords
Stroke; Large vessel occlusion; Endovascular thrombectomy; Intravenous thrombolysis; Reperfusion; Alteplase
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This study compared the efficacy between thrombectomy alone and thrombectomy with intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion. The results showed that although combined treatment increased successful reperfusion, it also increased the risk of overall intracranial hemorrhage. Thrombectomy alone was non-inferior to combined treatment in terms of functional independence at a 10% non-inferiority margin, but not at a 5% inferiority margin.
Background: It is unclear whether thrombectomy alone is non-inferior to thrombectomy with intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion.Purpose: To perform a comprehensive, trial-level data, non-inferiority meta-analysis of randomised controlled trials comparing endovascular thrombectomy with and without intravenous thrombolysis in patients with ischemic stroke due to large-vessel occlusion of anterior circulation.Methods: The prespecified primary efficacy outcome was functional independence, defined as a modified Rankin scale (mRS)score of 0 to 2 at 90 days. The two prespecified non-inferiority margins were risk differences of-10% and -5%. The study was registered in PROSPERO (CRD42022361110) and conducted according to PRISMA guidelines.Results: Six trials were included in this analysis (DIRECT-MT, DEVT, SKIP, MR CLEAN-NO IV, DIRECT-SAFE and SWIFT DIRECT) comprising a total of 2334 patients. Functional independence at 90 days was achieved by 570 (49.0%) of 1164 patients in the thrombectomy alone group and 595 (50.9%) of 1170 patients in the throm-bectomy with thrombolysis group (pooled risk difference -0.02, [95% CI-0.06-0.02]). Combined thrombec-tomy and thrombolysis were associated with significantly higher rates of successful reperfusion (pooled risk ratio 0.96 [95% CI, 0.93-0.99], p = 0.006) but at the expense of a significantly increased risk of overall -but not symptomatic -intracranial haemorrhage (pooled risk ratio 0.87 [95% CI, 0.77-0.98], p = 0.02).Conclusions: Compared with a combined treatment approach, thrombectomy alone was non-inferior at-10% non-inferiority margin, but not at a -5% inferiority margin for functional independence. Current evidence cannot exclude clinically important differences between the two treatment approaches.
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