Comparative Effectiveness of Intravenous Thrombolysis plus Mechanical Thrombectomy versus Mechanical Thrombectomy Alone in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

The treatment of acute ischemic stroke due to large artery vessel occlusion experienced a dramatic development within the last decade. This meta-analysis investigates the effectiveness of bridging therapy (BT) versus mechanical thrombectomy (MT) alone in treating acute ischemic stroke. Two independent reviewers assessed two-arm clinical trials from Scopus, PubMed, Web of Science, and the Cochrane Library up to January 2024. Data extraction and quality were evaluated using the ROBINS-2 tool. Our primary outcomes were improvement in NIHSS scores and 90-day modified Rankin Scale (mRS) score. This meta-analysis, which included 2,638 participants from 8 randomized controlled trials, found that BT resulted in a greater improvement in NIHSS scores from baseline compared to endovascular treatment alone (mean difference [MD] 0.96, 95% confidence interval [CI]: [0.73-1.20], p < 0.00001). Additionally, BT group achieved successful recanalization more frequently before and after thrombectomy. Thrombectomy alone hat a shorter time from stroke onset to groin puncture compared to BT (MD 9.91, 95% CI: [4.31-15.52], p = 0.005). Functional outcomes, mortality rates, symptomatic intracerebral hemorrhage rates, and long-term recovery metrics, such as Barthel index and modified Rankin Scale scores, were comparable between both treatment approaches. BT is superior to endovascular treatment alone based on NIHSS score improvement and successful reperfusion rates before and after thrombectomy. Despite MT alone demonstrating a shorter time from stroke onset to groin puncture (MD of 9.91 min), it did not contribute to greater NIHSS improvement at 24 h and 7 days. Further trials with larger sample sizes are warranted to enhance precision in clinical guidance.

Hammed A ，Al-Qiami A ，Alzawahreh A ，Rosenbauer J ，Nada EA ，Otmani Z ，Hamam NG ，Alnajjar AZ ，Mohamed Hammad E ，Hamamreh R ，Kostev K ，Richter G ，Tanislav C ... -  《-》

Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion.

Shafique MA ，Ali SMS ，Mustafa MS ，Aamir A ，Khuhro MS ，Arbani N ，Raza RA ，Abbasi MB ，Lucke-Wold B ... -  《-》

Intravenous thrombolysis before mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion; should we cross that bridge? A systematic review and meta-analysis of 36,123 patients.

The use of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (AIS-LVO) is a debatable subject in the field of neuro-interventional surgery. We conducted this systematic review and meta-analysis to synthesize evidence from published studies on the outcomes of IVT + MT compared with MT alone in AIS-LVO patients. We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to January 2022 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis DerSimonian-Liard random-effects model. Forty-nine studies, with a total of 36,123 patients, were included in this meta-analysis. IVT + MT was significantly superior to MT alone in terms of successful recanalization (RR 1.06, 95% CI 1.03 to 1.09), mortality (RR 0.75, 95% CI 0.68-0.82), favorable functional outcome (RR 1.21, 95% CI 1.13 to 1.29), and complete recanalization (RR 1.06, 95% CI 1.00 to 1.11). There were no significant differences between the two groups in terms of improvement of the National Institute of Health Stroke Scale (NIHSS) score at 24 h or at discharge (p > 0.05). Complications including symptomatic intracranial hemorrhage, symptomatic intracerebral hemorrhage (sICH), procedure-related complications, and parenchymal hematoma were comparable between the two groups (p > 0.05). For AIS-LVO, IVT + MT is associated with slightly better rates of survival, successful and complete recanalization, and favorable functional outcome as compared with MT alone. Further clinical trials are needed to corroborate such benefits of bridging IVT.

Ghaith HS ，Elfil M ，Gabra MD ，Nawar AA ，Abd-Alkhaleq MS ，Hamam KM ，Aboelnasr LE ，Elgezery EA ，Osman MH ，Elsayed H ，Swed S ，Kanmounye US ，Negida A ... -  《-》

Mechanical Thrombectomy in Acute Stroke Due to Carotid Occlusion: A Series of 153 Consecutive Patients.

Strokes due to carotid artery occlusion (CAO) are associated with bad clinical prognosis and poor response to intravenous thrombolysis. Several studies in the past have shown the benefits of mechanical thrombectomy (MT) and compared bridging therapy (BT) and primary MT (PMT) in large vessel occlusions, but only a few studies have focused on the specific population of CAO and their response to endovascular treatment. Retrospective review of patients treated at our center between January 2010 and June 2017 that (1) presented with acute ischemic stroke caused by CAO in the first 4.5 h since symptom onset, and (2) were treated with MT (BT or PMT). Baseline characteristics of the population, comparison between BT and PMT, intrahospital mortality, symptomatic intracranial hemorrhage, and functional outcome were investigated. A total of 153 patients were included. Baseline characteristics: 51.6% were male, and the median age was 71 years. The most frequent risk factor was hypertension (71.9%). The main stroke etiology was atherothrombotic (40.5%). The mean admission National Institute of Health Severity Score (NIHSS) was 19, mean discharge NIHSS was 7. Isolated occlusion of the Extracranial or Intracranial Internal Carotid Artery was the most frequent occlusion location (52.3%). TICI 2b-3 was achieved in 87.6%, intrahospital mortality was 26.8%, symptomatic hemorrhage was 8.5%, and 3 months-modified Rankin Score (mRS) 0-2 was 26.8%. Definitive carotid stenting was needed in 33.3% of the cases. BT versus PMT: Patients treated with PMT presented a higher incidence of atrial fibrillation, anticoagulation, and cardioembolic stroke compared to those treated with BT. No differences in TICI 2b-3, 3 months-mRS or symptomatic hemorrhage were found between both groups. Intrahospital mortality: Poor perfusion-CT mismatch (p = 0.005), isolated Internal carotid artery location (p = 0.024), and symptomatic hemorrhage (p < 0.001) were independent predictors. Symptomatic intracranial hemorrhage: Patients with post-treatment symptomatic hemorrhage had higher intrahospital mortality (p < 0.001) and worse 3 months-mRS (p = 0.033). Functional outcome: Admission NIHSS (p = 0.012) independently predicted 3 months-mRS. In our population, patients with CAO clinically present with severe strokes. Isolated occlusions of the extra- or intracranial segments of the carotid are more frequent than tandem occlusions. Successful recanalization after thrombectomy is achieved in most of the patients, but association with favorable functional outcome is poor. Clinical evolution is similar in patients treated with PMT and BT. Intracranial symptomatic hemorrhage after treatment is associated with higher intrahospital mortality and worse 3 months-mRS. Poor perfusion-CT mismatch, symptomatic hemorrhage, and isolated CAO are independent predictors of intrahospital mortality. Admission NIHSS is an independent predictor of 3 months-mRS.

Díaz-Pérez J ，Parrilla G ，Espinosa de Rueda M ，Cabrera-Maqueda JM ，García-Villalba B ，Alba-Isasi MT ，Morales A ，Zamarro J ... -  《-》

Comparison of Risk Factors, Safety, and Efficacy Outcomes of Mechanical Thrombectomy in Posterior vs. Anterior Circulation Large Vessel Occlusion.

Background and Purpose: It is believed that stroke occurring due to posterior circulation large vessel occlusion (PCLVO) and that occurring due to anterior circulation large vessel occlusion (ACLVO) differ in terms of their pathophysiology and the outcome of their acute management in relation to endovascular mechanical thrombectomy (MT). Limited sample size and few randomized controlled trials (RCTs) with respect to PCLVO make the safety and efficacy of MT, which has been confirmed in ACLVO, difficult to assess in the posterior circulation. We therefore conducted a meta-analysis to study to which extent MT in PCLVO differs from ACLVO. Materials and Methods: We searched the databases PubMed, Cochrane, and EMBASE for studies published between 2010 and January 2021, with information on risk factors, safety, and efficacy outcomes of MT in PCLVO vs. ACLVO and conducted a systematic review and meta-analysis; we compared baseline characteristics, reperfusion treatment profiles [including rates of intravenous thrombolysis (IVT) and onset-to-IVT and onset-to-groin puncture times], recanalization success [Thrombolysis In Cerebral Infarction scale (TICI) 2b/3], symptomatic intracranial hemorrhage (sICH), and favorable functional outcome [modified Rankin Score (mRS) 0-2] and mortality at 90 days. Results: Sixteen studies with MT PCLVO (1,172 patients) and ACLVO (7,726 patients) were obtained from the search. The pooled estimates showed higher baseline National Institutes of Health Stroke Scale (NIHSS) score (SMD 0.32, 95% CI 0.15-0.48) in the PCLVO group. PCLVO patients received less often IVT (OR 0.65, 95% CI 0.53-0.79). Onset-to-IVT time (SMD 0.86, 95% CI 0.45-1.26) and onset-to-groin puncture time (SMD 0.59, 95% CI 0.33-0.85) were longer in the PCLVO group. The likelihood of obtaining successful recanalization and favorable functional outcome at 90 days was comparable between the two groups. PCLVO was, however, associated with less sICH (OR 0.56, 95% CI 0.37-0.85) but higher mortality (OR 1.92, 95% CI 1.46-2.53). Conclusions: This meta-analysis indicates that MT in PCLVO may be comparably efficient in obtaining successful recanalization and 90 day favorable functional outcome just as in ACLVO. Less sICH in MT-treated PCLVO patients might be the result of the lower IVT rate in this group. Higher baseline NIHSS and longer onset-to-IVT and onset-to-groin puncture times may have contributed to a higher 90 day mortality in PCLVO patients.

Mbroh J ，Poli K ，Tünnerhoff J ，Gomez-Exposito A ，Wang Y ，Bender B ，Hempel JM ，Hennersdorf F ，Feil K ，Mengel A ，Ziemann U ，Poli S ... -  《Frontiers in Neurology》