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Meta-analysis of randomized intra-arterial thrombolytic trials for the treatment of acute stroke due to middle cerebral artery occlusion
  1. Jeremy D Fields1,2,
  2. Pooja Khatri3,
  3. Gary M Nesbit1,
  4. Kenneth C Liu4,
  5. Stanley L Barnwell1,
  6. Helmi L Lutsep5,
  7. Wayne M Clark5,
  8. Maarten G Lansberg6
  1. 1Interventional Neuroradiology, Oregon Health and Science University, Portland, Oregon, USA
  2. 2Neurosciences Critical Care, Oregon Health and Science University, Portland, Oregon, USA
  3. 3Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
  4. 4Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
  5. 5Oregon Stroke Center, Oregon Health and Science University, Portland, Oregon, USA
  6. 6Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA
  1. Correspondence to Dr J D Fields, Oregon Health and Science University, Departments of Neurology and Interventional Neuroradiology, 3181 SW Sam Jackson Park Road, CR-127, Portland, Oregon 97239-3098, USA; fieldsje{at}ohsu.edu

Abstract

Background Randomized clinical trials supporting the use of intra-arterial administration of thrombolytics (IAT) for the treatment of stroke due to middle cerebral artery (MCA) occlusion have been positive on some, but not all, endpoints. A meta-analysis was performed to estimate with more precision the effect of IAT on several key clinical endpoints.

Methods All randomized trials of IAT in the treatment of MCA stroke were identified by PUBMED search and by hand search of potentially relevant references. Trial methodologies were assessed for compatibility in study protocols and statistical analysis. A meta-analysis was performed evaluating the effect of IAT on functional outcome at 90 days and symptomatic intracranial hemorrhage (SICH) within 24 h.

Results Three trials met the criteria for the meta-analysis. IAT treated patients were significantly more likely to have a modified Rankin scale (mRS) ≤1 (31% vs 20%, OR 2.0, 95% CI 1.2 to 3.4, p=0.01); mRS ≤2 (43% vs 31%, OR 1.9, 95% CI 1.2 to 3.0, p=0.01); and NIH Stroke Scale score 0 or 1 (23% vs 12%, OR 2.4, 95% CI 1.3 to 4.4, p=0.007) at the 90 day follow-up. There was no effect on mortality at 90 days (20% vs 19%, OR 0.84, 95% CI 0.5 to 1.5). The risk of SICH was significantly increased in the active treatment arms (11% vs 2%, OR 4.6, 95% CI 1.3 to 16, p=0.02).

Conclusions Our meta-analysis demonstrates that all standard functional endpoints for stroke trials were substantially improved in the active treatment arms. Despite an increased risk of SICH, there was no effect on mortality. These results support endovascular treatment of acute ischemic stroke due to MCA occlusion with intra-arterial thrombolytics.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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