Title: Intravenous Thrombolysis followed by Endovascular Thrombectomy compared with Direct Endovascular Thrombectomy for Stroke: a Systematic Review and Meta-analysis of Randomized and Non-Randomized Studies
Authors: Maurish Fatima, Saleha Azeem, Hafsa Shahid, Muhammmad Ayyan, Afra Zahid, Muhammmad Faiq Umar, Salman Sani, Aleena Ahmed, Huzaifa Ahmad Cheema, Bakhtawar Ahmad, Muhammad Aemaz Ur Rehman, Muhammad Ebad UR Rehman, Waseem Khaliq, and Jamir Pitton Rissardo
Conference: 2023 AAN Annual Meeting, Boton, MA
Objective: To address the conflicting results of available trials, we conducted a systematic review and meta-analysis to evaluate if direct endovascular thrombectomy (DEVT) was non-inferior to BT (Bridging thrombolysis) for efficacy and safety in patients with Acute Ischemic Stroke (AIS) due to large vessel Occlusion (LVO) who were eligible for IVT based on data available in the form of Randomized Controlled Trials and NRS (Non-Randomized Studies).
Background: The effectiveness of DEVT as compared to BT for patients with AIS-LVO is still debatable due to limited published head-to-head trials.
Design/Methods: A literature search was conducted on PubMed, Cochrane, and Embase from inception till July 2022. All the eligible RCTs and NRS were included in the analysis. ReVman was employed for statistical analysis. Random effect model was utilized. RoB2 and ROBINS were used for quality appraisal.
Results: After rigorous screening, a total of six RCTs and four NRS consisting of a total of 3,662 patients were included. The pooled analysis of the 90-day functional independence (modified Rankin Scale 0–2) reported a risk difference (RD) of 1% (95% CI; −0.04, 0.03, I2= 0 %). With a 5% non-inferiority margin, the DEVT group presented a non-inferiority as compared to the BT group. The results did not report any significant association of the type of procedure with mortality (OR:0.96,95%CI; 0.78, 1.18, P= 0.70, I2= 23%) and rate of successful recanalization (OR: 0.89 95%CI; 0.67, 1.18, P= 0.41) The results indicated a statistically significant lower risk of symptomatic intracranial hemorrhage (sICH) (OR: 0.72, 95% CI; 0.55, 0.95, P = 0.02) for DEVT as compared to BT.
Conclusions: Our meta-analysis reported that DEVT alone shows non-inferior effectiveness in 90-day functional independence and the incidence of sICH. Future studies need to include population with broader age group and ethnic/racial diversities for better understanding of current guidelines.
Figure 1. Analysis of the 90-day functional independence (modified Rankin Scale 0-2) reported a risk difference (RD) of 1% (95% CI; -0.04, 0.03, I2 = 0%).
Figure 2. Significant lower risk of symptomatic intracranial hemorrhage (OR: 0.72, 95% CI; 0.55, 0.95, P = 0.02) for direct endovascular thrombectomy (DEVT) as compared to bridging thrombolysis (BT).