Mechanical thrombectomy for emergent large vessel occlusion

A critical appraisal of recent randomized controlled clinical trials

Georgios Tsivgoulis, Apostolos Safouris, Aristeidis H. Katsanos, Adam Arthur, Andrei Alexandrov

Research output: Contribution to journalArticle

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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 (I2 = 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 (I2 < 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. MT is a safe and highly effective treatment for patients with emergent large vessel occlusion (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 best medical therapy.

Original languageEnglish (US)
Pages (from-to)1-8
Number of pages8
JournalBrain and Behavior
Volume6
Issue number2
DOIs
StatePublished - Feb 1 2016

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Thrombectomy
Randomized Controlled Trials
Reperfusion
Intracranial Hemorrhages
Therapeutics
Mortality
Cerebrovascular Circulation
Stents

All Science Journal Classification (ASJC) codes

  • Behavioral Neuroscience

Cite this

Mechanical thrombectomy for emergent large vessel occlusion : A critical appraisal of recent randomized controlled clinical trials. / Tsivgoulis, Georgios; Safouris, Apostolos; Katsanos, Aristeidis H.; Arthur, Adam; Alexandrov, Andrei.

In: Brain and Behavior, Vol. 6, No. 2, 01.02.2016, p. 1-8.

Research output: Contribution to journalArticle

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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 (I2 = 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 (I2 < 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. MT is a safe and highly effective treatment for patients with emergent large vessel occlusion (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 best medical therapy.",
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