Meta-analysis Supports Endovascular Therapy for Acute Stroke

Functional outcomes in patients with acute ischemic stroke are improved when endovascular therapy is used in conjunction with standard fibrinolysis, according to a meta-analysis of contemporary trials published online June 13, 2015, ahead of print in the European Heart Journal.

Researchers led by Partha Sardar, MD, of the University of Utah Health Care (Salt Lake City, UT), examined 8 RCTs of endovascular therapy plus fibrinolytic therapy (if eligible) vs fibrinolytic therapy alone published between 2013 and 2015.

They included 2,423 patients (median age 67.4 years; 53.2% men) with acute ischemic stroke due to large artery occlusions in the anterior circulation. Endovascular therapy and control groups had similar baseline characteristics.

Functional Outcomes Improve With Endovascular Therapy

Researchers assessed the pooled data for good functional outcome (primary endpoint), all-cause mortality, and symptomatic intracerebral hemorrhage. 

Overall, functional independence at 90 days (modified Rankin Scale 0-2) was more common in patients who received endovascular therapy vs fibrinolytic therapy alone (OR 1.73; 95% CI 1.18-2.53).

Five of the trials were completed in 2015 (n = 1,287), and they showed an even stronger relationship between endovascular therapy and functional independence (pooled OR 2.42; 95% CI 1.91-3.08) than the 3 trials published in 2013. Each individual trial showed a benefit (table 1).

Rates of mortality and symptomatic intracerebral hemorrhage did not differ between groups in either the overall analysis or among the newer trials.

Updated Guidelines on the Horizon

The evolution of endovascular therapy in recent years may have contributed to producing strong functional outcomes, the study authors say. Specifically, these trials “selected patients meticulously with the use of computed tomographic angiography (CTA) or perfusion imaging and used modern stent-retriever procedures for reperfusion,” they write.

Dr. Sardar added in an email with TCTMD that “proper patient selection to identify large-vessel occlusions using imaging studies such as CT angiography with or without perfusion imaging is critical to therapeutic success.”

The authors urge caution in interpreting the results, however, given that their meta-analysis was performed using data from a select group. “The trials included in the analysis were conducted at select endovascular centers with highly experienced neurointerventionalists and with efficient stroke evaluation systems in place,” they write. “At present, this level of efficiency, stroke expertise, and neurointerventional experience is not uniformly available in all community hospitals, which might limit the immediate generalizability of our results.”

Dr. Sardar noted that even though there was not a mortality difference observed, “it would be interesting to see if future trials and further pooled analysis show any statistically significant mortality benefit with endovascular therapy.”

In the meantime, clinicians can expect updated practice guidelines based on current data. Joseph Broderick, MD, of University of Cincinnati Medical Center/Christ Hospital (Cincinnati, OH), told TCTMD in an email that “at the end of the month [June], the updated guidelines from the American Heart Association for treatment of acute ischemic stroke will provide detailed analysis of the endovascular trials.”

Note: Coauthor William Gray is a faculty member of the Cardiovascular Research Foundation, which owns and operates TCTMD.

Nicole Lou is the 2015 Recipient of the Jason Kahn Fellowship in Medical Journalism