(SSC) Cerebrovascular Section Best Clinical Scientific Paper Abstract Award Resident/fellow (2023 Award Winner): Endovascular Thrombectomy versus Endovascular Thrombectomy Preceded by Intravenous Thrombolysis for Patients with Acute Ischemic Stroke
Post-Doctoral Research Fellow Johns Hopkins University School of Medicine
Disclosure(s):
Shahab Aldin Sattari, MD: No financial relationships to disclose
Introduction: Randomized controlled trials (RCTs) comparing endovascular thrombectomy (EVT) versus EVT preceded by intravenous tissue plasminogen activator (iv tPA) are debatable. This systematic review and meta-analysis sought to reach a consensus in this regard.
Methods: MEDLINE, PubMed, and Embase were searched. The primary outcome was mRS 0-2 at 90-days. Secondary outcomes were mRS 0-1, mean mRS, NIHSS, Barthel Index of 95-100, EQ-5D-5l, the volume of infarction (ml), successful reperfusion, complete reperfusion, recanalization, mortality, any ICH, symptomatic ICH, embolization in new territory, new infarction, puncture site complications (i.e., groin hematoma or pseudoaneurysm), vessel dissection, and contrast extravasation. The certainty in evidence was determined by the GRADE approach. Online Prospero registration # CRD42022357506.
Results: Six RCTs yielding 2332 patients were included, in which 1163 and 1169 underwent EVT and EVT preceded by iv tPA, respectively. The relative risk of mRS 0-2 at 90 days was similar (RR=0.96[0.88, 1.04], p=0.28). EVT was non-inferior to EVT preceded by iv tPA because the lower bond of 95% CI of the risk difference (RD=-0.02 (-0.06, 0.02), p=0.36) lies above the non-inferiority margin of -0.1. The certainty of the evidence was high. The RR of successful reperfusion (RR= 0.96 (0.93, 0.99, p=0.006), any ICH (RR=0.87 (0.77, 0.98), p=0.02), and puncture site complications (RR=0.47 (0.25, 0.88), p=0.02) were lower with EVT. For the EVT preceded by iv tPA, the number needed to treat (NNT) for successful reperfusion was 25, and the number needed to harm (NNH) for any ICH and puncture site complications was 20 and 33, respectively. The two groups were similar in other outcomes.
Conclusion : EVT is non-inferior to EVT preceded by iv tPA. Furthermore, the NNH of ICH is lower than the NNT of successful reperfusion for EVT preceded by iv tPA. Therefore, it seems reasonable to bypass initial iv tPA if timely EVT is deemed possible.
