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Original research
Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis
  1. Kevin Phan1,2,
  2. Adam A Dmytriw3,4,
  3. Declan Lloyd5,
  4. Julian M Maingard6,7,
  5. Hong Kuan Kok8,
  6. Ronil V Chandra7,
  7. Mark Brooks6,
  8. Vincent Thijs9,10,
  9. Justin M Moore3,
  10. Albert Ho Yuen Chiu11,
  11. Magdy Selim12,
  12. Mayank Goyal13,
  13. Vitor Mendes Pereira4,
  14. Ajith J Thomas3,
  15. Joshua A Hirsch14,
  16. Hamed Asadi6,7,
  17. Nelson Wang2
  1. 1 NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia
  2. 2 Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  3. 3 Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
  4. 4 Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  5. 5 School of Medicine, The University of Notre Dame, Sydney, New South Wales, Australia
  6. 6 Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
  7. 7 Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia
  8. 8 Department of Interventional Radiology, Guy’s and St Thomas' NHS Foundation Trust, London, UK
  9. 9 Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Belgium
  10. 10 Department of Neurology, Austin Health, Melbourne, Victoria, Australia
  11. 11 Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital and Community Health Services, Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
  12. 12 Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  13. 13 Diagnostic and Interventional Neuroradiology, University of Calgary, Calgary, Alberta, Canada
  14. 14 Massachusetts General Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Adam A Dmytriw, Department of Medical Imaging, University of Toronto, Toronto, B3H 1X5, Canada; adam.dmytriw{at}


Objectives The present Bayesian network meta-analysis aimed to compare the various strategies for acute ischemic stroke: direct endovascular thrombectomy within the thrombolysis window in patients with no contraindications to thrombolysis (DEVT); (2) direct endovascular thrombectomy secondary to contraindications to thrombolysis (DEVTc); (3) endovascular thrombectomy in addition to thrombolysis (IVEVT); and (4) thrombolysis without thrombectomy (IVT).

Methods Six electronic databases were searched from their dates of inception to May 2017 to identify randomized controlled trials (RCTs) comparing IVT versus IVEVT, and prospective registry studies comparing IVEVT versus DEVT or IVEVT versus DEVTc. Network meta-analyses were performed using ORs and 95% CIs as the summary statistic.

Results We identified 12 studies (5 RCTs, 7 prospective cohort) with a total of 3161 patients for analysis. There was no significant difference in good functional outcome at 90 days (modified Rankin Scale score ≤2) between DEVT and IVEVT. There was no significant difference in mortality between all treatment groups. DEVT was associated with a 49% reduction in intracranial hemorrhage (ICH) compared with IVEVT (OR 0.51; 95% CI 0.33 to 0.79), due to reduction in rates of asymptomatic ICH (OR 0.47; 95% CI 0.29 to 0.76). Patients treated with DEVT had higher rates of reperfusion compared with IVEVT (OR 1.73; 95% CI 1.04 to 2.94).

Conclusions To our knowledge, this is the first network meta-analysis to be performed in the era of contemporary mechanical thrombectomy comparing DEVT and DEVTc. Our analysis suggests the addition of thrombolysis prior to thrombectomy for large vessel occlusions may not be associated with improved outcomes.

  • stroke
  • thrombectomy
  • thrombolysis

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  • KP and AAD contributed equally.

  • Contributors All authors made substantial contributions to the conception or design of the work, drafting the work or revising it critically for important intellectual content, final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

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