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A meta-analysis of prospective randomized controlled trials evaluating endovascular therapies for acute ischemic stroke
  1. Kyle M Fargen1,
  2. Dan Neal1,
  3. David J Fiorella2,
  4. Aquilla S Turk3,
  5. Michael Froehler4,
  6. J Mocco5
  1. 1Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  2. 2Cerebrovascular Center, Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, NY, USA
  3. 3Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee, USA
  5. 5Department of Neurosurgery, New York, New York, USA
  1. Correspondence to Dr Kyle M Fargen, Department of Neurosurgery, University of Florida, Box 100265, Gainesville, FL 32610, USA; kyle.fargen{at}neurosurgery.ufl.edu

Abstract

Introduction A recent randomized controlled trial (RCT), the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN), demonstrated better outcomes with endovascular treatment compared with medical therapy for acute ischemic stroke (AIS). However, previous trials have provided mixed results regarding the efficacy of endovascular treatment for AIS. A meta-analysis of all available trial data was performed to summarize the available evidence.

Methods A literature search was performed to identify all prospective RCTs comparing endovascular therapies with medical management for AIS. Two datasets were created: (1) all patients randomized after confirmation of large vessel occlusion (LVO) (consistent with the contemporary standard of practice at the majority of centers); and (2) all patients with outcome data who underwent randomization regardless of qualifying vascular imaging. The pre-specified primary outcome measure was modified Rankin Scale score of 0–2 at 90 days. A fixed-effect model was used to determine significance.

Results Five prospective RCTs comparing endovascular therapies with medical management were included in dataset 1 (1183 patients) and six were included in dataset 2 (1903 total patients). Endovascular therapies were associated with significantly improved outcomes compared with medical management (OR 1.67, 95% CI 1.29 to 1.16, p=0.0001) for patients with LVO (dataset 1). This benefit persisted when patients from all six RCTs were included, even in the absence of confirmation of LVO (OR 1.27, 95% CI 1.05 to 1.54, p=0.019; dataset 2).

Conclusions A meta-analysis of prospective RCTs comparing endovascular therapies with medical management demonstrates superior outcomes in patients randomized to endovascular therapy.

  • Stroke
  • Thrombectomy
  • Thrombolysis

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