ArticlesImaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data
Introduction
Randomised clinical trials from the past 3 years have established the safety and efficacy of endovascular thrombectomy (EVT) in the treatment of patients with acute ischaemic stroke and proximal anterior circulation occlusion.1, 2, 3, 4, 5, 6, 7, 8 Because the clinical benefit observed in these trials was time dependent, the need for fast and efficient patient selection is well recognised.9 Imaging is widely used to determine prognosis and to select patients for EVT.10, 11, 12 After the results of five trials were reported in 2015, the new American Heart Association guidelines13 recommended EVT as standard of care (level I, class A evidence) in patients with a baseline non-contrast Alberta Stroke Program Early CT Score (ASPECTS) between 6 and 10.
Imaging features are strong predictors of clinical outcome.10 Large infarcts at baseline, large thrombi in proximal arteries, and poor collateral circulation identified with imaging are associated with overall lower likelihood of functional independence and increased risk of intracranial haemorrhage after reperfusion therapies.14, 15, 16, 17, 18, 19 However, evidence regarding whether these imaging features are useful for selecting patients for EVT is scarce. This patient-level meta-analysis by the highly effective reperfusion evaluated in multiple endovascular stroke trials (HERMES) collaboration aims to determine safety and efficacy of EVT compared with standard medical therapy, by baseline imaging features.
Section snippets
Search strategy and selection criteria
In this individual patient-level meta-analysis, we searched PubMed for randomised trials published between Jan 1, 2010, and Oct 31, 2017, which compared EVT predominantly done with stent retrievers with standard care in patients with anterior circulation ischaemic stroke. The PubMed search string was ((“randomized controlled trial”[Publication Type]) AND ((thrombectomy [Title/Abstract]) OR (clot retrieval [Title/Abstract]) OR intraarterial[Title/Abstract]) AND (stroke[Title/Abstract]) AND
Results
We obtained data from 1764 randomised participants, of whom 871 were assigned to receive EVT and 893 to receive standard medical treatment (control group). Pre-randomisation brain imaging features were evaluated in 1388 patients on CT and in 364 patients on MRI (appendix). Clinical characteristics and imaging features at baseline were balanced between the two treatment groups, but treatment with intravenous alteplase was more common in the control group (table 1). Risk of bias was low except in
Discussion
Our patient-level meta-analysis lends support to a benefit of EVT for acute ischaemic stroke across a broad range of imaging subgroups. Our results add to previous work from the HERMES collaboration that showed benefit of EVT across a broad range of clinical subgroups.8 Our analysis is larger than this previous work (seven trials instead of five and 1764 patients instead of 1287), uses more rigorous imaging analysis (HERMES core laboratory uniform rereading of all scans from all trials), and
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