Interventions for hypertension and stroke

Mechanical thrombectomy with retrievable stents and aspiration catheters for acute ischaemic stroke: a meta-analysis of randomised controlled trials

EuroIntervention 2022;17:e1425-e1434. DOI: 10.4244/EIJ-D-21-00343

Christopher Rajkumar
Christopher A. Rajkumar1,2, MBBS, BSc; Sashiananthan Ganesananthan1, BSc; Yousif Ahmad1,3, MBBS, BSc; Henry Seligman1,2, MBBS, MA; George D. Thornton4,5, MBBS, BSc; Michael Foley1,2, MBBS, BSc; Alexandra N. Nowbar1,2, MBBS, BSc; James P. Howard1,2, MA, MBBChir; Darrel P. Francis1,2, MBBS, MA, MBBChir; Thomas R. Keeble6,7, MBBS, MD, BSc; Iris Q. Grunwald7,8, MD; Rasha K. Al-Lamee1,2, MBBS, MA, PhD; Iqbal Malik2, MA, MBBChir, PhD; Matthew J. Shun-Shin1,2, MBBCh, MA, PhD
1. National Heart and Lung Institute, Imperial College London, London, United Kingdom; 2. Imperial College Healthcare NHS Trust, London, United Kingdom; 3. Cedars-Sinai Medical Center, Los Angeles, CA, USA; 4. University College London, London, United Kingdom; 5. Barts Heart Centre at St Bartholomew's Hospital, London, United Kingdom; 6. Essex Cardiothoracic Centre, Basildon, United Kingdom; 7. Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom; 8. University of Dundee, Dundee, United Kingdom

Background: Retrievable stents and aspiration catheters have been developed to provide more effective arterial recanalisation in acute ischaemic stroke.

Aims: The aim of this analysis was to test the effect of mechanical thrombectomy on mortality and long-term neurological outcome in patients presenting with acute large-vessel anterior circulation ischaemic stroke.

Methods: A structured search identified randomised controlled trials of thrombectomy (using a retrievable stent or aspiration catheter) versus control on a background of medical therapy which included intravenous thrombolysis if appropriate. The primary endpoint was disability at 90-day follow-up as assessed by the modified Rankin scale (mRS). Secondary endpoints included all-cause mortality and symptomatic intracranial haemorrhage. A Bayesian mixed-effects model was used for analysis.

Results: Twelve trials met the inclusion criteria, comprising a total of 1,276 patients randomised to thrombectomy and 1,282 patients to control. Randomisation to thrombectomy significantly reduced disability at 90 days (odds ratio [OR] 0.52, 95% credible interval [CrI] 0.46 to 0.61, probability(control better)<0.0001). Furthermore, thrombectomy reduced the odds of functional dependence at 90 days, indicated by an mRS score >2 (OR 0.44, CrI 0.37 to 0.52, p<0.0001). Thrombectomy reduced all-cause mortality at 90 days (16.1% vs 19.2%, OR 0.81, 95% CrI 0.66 to 0.99, p=0.024). The frequency of symptomatic intracranial haemorrhage was similar between thrombectomy (4.2%) and control (4.0%) (OR 1.12, 95% CrI 0.76 to 1.68, p=0.72).

Conclusions: In patients with an acute anterior circulation stroke, modern device thrombectomy significantly reduces death and subsequent disability. The magnitude of these effects suggests that universal access to this treatment strategy should be the standard of care.

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ischaemic strokeStent retrieversthrombectomy
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