Clinical evidence comparing bridging and direct endovascular thrombectomy: progress and controversies

Abstract

Clinical evidence comparing bridging endovascular thrombectomy (bEVT) with intravenous thrombolysis and direct endovascular thrombectomy (dEVT) without thrombolysis for patients with acute ischemic stroke (AIS) presented directly to an EVT-capable center is overwhelming but inconsistent. This study aimed to analyze the progress and controversies in clinical evidence based on current meta-analyses. Three databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched. Relevant data were extracted and reviewed from the pooled studies. The Assessment of Multiple Systematic Review (AMSTAR-2) was used for quality assessment. Twenty-five meta-analyses were finally included. There were 56% (14/25) from Asian countries, 20% (5/25) from North America, and 24% (6/25) from Europe. The majority (72%, 18/25) of evidence arose in a short period from 2020 to 2022 with the serial publication of four randomized controlled trials (RCTs). Among the 25 meta-analyses, 11 pooled at least three RCTs but there is substantial overlap among seven (five recruited the same four RCTs solely and two recruited the same three RCTs solely). Meanwhile, quality rating based on AMSTAR-2 showed 16 ‘high’ rated studies (64%). For functional independence, 40% (10/25) of studies favored bEVT and 60% showed neutral results. For symptomatic intracerebral hemorrhage, most studies (82.6%, 19/23) showed no significant difference. Non-RCT studies contributed to evidence favoring bEVT. Current RCTs provide an update of clinical evidence comparing bEVT and dEVT. However, they simultaneously contribute to an unnecessary overlap among studies. Contemporary observational studies demonstrated different but possibly confounded evidence. Thus, this issue still requires more clinical evidence under standard procedures.

Hemorrhagic Transformation Assessment Based on Dual Energy CT of Immediately and Twenty-Four Hours after Endovascular Thrombectomy for Acute Ischemic Stroke

“…Further multicenter, large-sample, and well-designed prospective studies are needed in the future. Finally, the proportion of patients with AIS in whom direct EVT was performed who met the indications in our hospital was higher than that in previous studies, and the differences in treatment modalities may also have limited the extrapolation value of the conclusions of this study to some extent [24,25].…”

“…This is because understanding delayed HT and determining its incidence rate is essential, given the potential risks associated with this type of ICH, such as worsened patient condition, prognosis, and increased risk of death upon occurrence. Moreover, treatment strategies for EVT vary among different medical centers, with some centers leaning towards bridging therapy and others preferring direct EVT [24]. These differences in treatment modalities may influence the proportion of delayed HT in patients post-EVT, as various factors, including direct vascular damage caused by different surgical methods during interventional therapy and the toxic side effects of thrombolytic drugs, are associated with post-EVT hemorrhagic transformation.…”