J Stroke.  2021 Sep;23(3):358-366. 10.5853/jos.2021.00724.

Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis

• Kerleroux B
• Janot K
• Hak JF
• Kaesmacher J
• Hassen WB
• Benzakoun J
• Oppenheim C
• Herbreteau D
• Ifergan H
• Bricout N
• Henon H
• Yoshimoto T
• Inoue M
• Consoli A
• Costalat V
• Naggara O
• Lapergue B
• Cagnazzo F
• Boulouis G

• KMID: 2520913
• DOI: http://doi.org/10.5853/jos.2021.00724

Abstract

The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I²=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I²=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I²=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I²=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I²=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.

Keyword

Stroke; Ischemic stroke; Thrombectomy

Figure

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  Figure 1. Flowchart for studies selection. BMT, best medical treatment.

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  Figure 2. Forest plot for the rates of patients with 90-day unfavorable outcome after mechanical thrombectomy. Unfavorable outcome=modified Rankin Scale (mRS) of 3 or more at 90-day. CI, confidence interval; CTP, computed tomography-perfusion; MRI, magnetic resonance imaging.

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  Figure 3. Forest plot showing the effect on 90-day unfavorable outcome (modified Rankin Scale of 3 or more) of (A) mechanical thrombectomy (MT) vs. best medical treatment (BMT) and (B) MT vs. BMT without considering reperfusion status. OR, odds ratio; CI, confidence interval. *Considering successful reperfusion (thrombolysis in cerebral infarction [TICI] 2b-3) vs. unsuccessful reperfusion (TICI 0-2a).

Reference

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