Effect of endovascular therapy in large anterior circulation ischaemic strokes: A systematic review and meta-analysis of randomised controlled trials

Abstract

Introduction: The benefit of endovascular treatment in large anterior circulation ischaemic strokes with low ASPECTS score (<6) is uncertain. Recent randomised studies have demonstrated the benefit of endovascular treatment (EVT) in large ischaemic strokes. The present meta-analysis aims to assess the combined effect of these studies on efficacy and safety of endovascular treatment in this group of patients. Materials and methods: We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases MEDLINE, PubMed, EMBASE, SCOPUS, Google Scholar, Tripdatabase were searched for randomised controlled trials with at least 50 participants from inception until February 16, 2023. The primary efficacy outcome analysed was the relative risk of functional independence defined as mRS – 0–2 at 90 days. Secondary efficacy outcomes included early neurological improvement, death due to any cause at 90 days and proportion of patients requiring decompressive hemicraniectomy. The primary safety outcome was the risk of developing symptomatic intracerebral haemorrhage (sICH). Results: A total of three studies (RESCUE Japan-LIMIT, SELECT 2 and ANGEL ASPECTS) involving 1011 patients; 510 in the EVT arm and 501 in the medical management (MM) arm met the defined criteria (ASPECTS-3-5). The combined RR for the primary outcome of mRS 0–2 was 2.53 [1.84–3.47] ( p = <0.0001) favouring EVT over MM. The primary safety outcome of sICH was not significant in the EVT arm with a combined RR of 1.84 [0.94–3.60] ( p = 0.5157). Mortality rates were similar in both arms (26.67% in EVT arm vs 27.94% in MM arm) with a combined RR of 0.95 [0.78; 1.16] ( p = 1.000). Conclusion: In patients with Large vessel occlusion (LVO) and low ASPECTS (3–5), EVT was associated with higher likelihood of achieving functional independence and early neurologic improvement but did not provide any mortality benefit.

Getting to the Core of Stroke

“…Though there were overall more patients with intracerebral hemorrhage (ICH) with EVT, no significant difference was observed in symptomatic ICH and mortality between the EVT and medical management arms. [ 9 ]…”

“…Functional independence (mRS 0–2) was achieved in 28% and was comparable to the meta-analysis results (119/510 [23.3%]). [ 9 ] Early neurologic recovery, symptomatic intracerebral hemorrhage (sICH), decompressive hemicraniectomy, and mortality were noted in 12%, 16%, 28%, and 36%, respectively. Though this study provides relevant real-world data on younger Indian patients with a median age of 53 years (range 27–75 years), it has inherent limitations of a small sample size, retrospective nonrandomized, design, and absence of a comparator group.…”

“…Even with better ASPECTS and a lower rate of intravenous thrombolysis (8% vs. 20%–30%) before EVT, 16% patients had symptomatic intracerebral hemorrhage in the present study (vs. expected 6%–8.9% from the meta-analysis). [ 9 ] This could be multifactorial, mainly due to higher rate of recanalization (Thrombolysis in cerebral infarction [TICI] 2b/3 in 92%), delay in EVT (48% underwent procedure after 6 h from ictus), periprocedural settings, or post-EVT factors like blood pressure control and antithrombotic initiation. Exact criteria used to estimate the mismatch in patients who presented later than 6 h from ictus is not mentioned in this study.…”