You are here

  • Home
  • Online First
  • Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

Article Text

Article menu
Download PDFPDF
Ischemic stroke
Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis
  1. Omar Marei1,
  2. Anna Podlasek2,
  3. Emma Soo1,
  4. Waleed Butt3,
  5. Benjamin Gory4,
  6. Thanh N Nguyen5,6,
  7. Jason P Appleton7,8,
  8. Sébastien Richard9,
  9. Hal Rice10,
  10. Laetitia de Villiers10,
  11. Vinicius Carraro do Nascimento10,
  12. Luis Domitrovic10,
  13. Norman McConachie11,
  14. Robert Lenthall11,
  15. Sujit Nair11,
  16. Luqman Malik11,
  17. Jasmin Panesar11,
  18. Kailash Krishnan7,12,
  19. Pervinder Bhogal13,
  20. Robert A Dineen1,14,
  21. Timothy J England12,15,
  22. Bruce C V Campbell16,17,
  23. Permesh Singh Dhillon1,10
  1. 1Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
  2. 2Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
  3. 3Queen Elizabeth Hospital Birmingham, Birmingham, UK
  4. 4Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
  5. 5Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
  6. 6Radiology, Boston Medical Center Department of Radiology, Boston, Massachusetts, USA
  7. 7Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
  8. 8Stroke Trials Unit, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
  9. 9Department of Neurology, Université de Lorraine, Nancy, France
  10. 10Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
  11. 11Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
  12. 12Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
  13. 13Interventional Neuroradiology, Royal London Hospital, London, UK
  14. 14NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
  15. 15Stroke Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
  16. 16Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
  17. 17Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
  1. Correspondence to Dr Permesh Singh Dhillon, Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK; permesh.dhillon{at}nottingham.ac.uk

Abstract

Background Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis.

Methods Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0–2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

Results 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I2=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I2=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I2=76%) were not significantly different.

Conclusion The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.

  • Stroke
  • Thrombectomy
  • Thrombolysis
  • Embolic
  • Hemorrhage

Data availability statement

All data used for analyses are available within the article and the original publications of included studies. Not applicable.

https://doi.org/10.1136/jnis-2023-021244

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    All data used for analyses are available within the article and the original publications of included studies. Not applicable.

    View Full Text

    Footnotes

    • Twitter @NguyenThanhMD, @carrarovini, @PermeshSD

    • Contributors Conception and design: PSD. Study search and review: OM, AP, ES, PSD. Analysis and interpretation of the data: OM, AP, PSD, WB. Critical revision and approval of the final version of the manuscript: all authors. PSD is guarantor of the study.

    • 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 TNN reported research support from Medtronic and SVIN; advisory board with Idorsia. PB reported travel support from Perflow; compensation from Cerenovus, Balt USA, LLC, Vesalio, Phenox Inc, and Brainomix for consultant services. BG has received grants from the French Ministry of Health and is the primary investigator of the TITAN, DIRECT ANGIO, and IA-RESCUE trial, and consulting fees from Air Liquide, MIVI, Medtronic, Boerhinger Ingelheim, Microvention, and Penumbra. JPA is supported, in part, by an NIHR Health and Care Research Scholarship. KK is a recipient of a research fellowship awarded by the Nottingham University Hospitals NHS Trust. There are no other disclosures or competing interests declared by the remaining authors.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.