Original ArticleRescue Intracranial Stenting After Failed Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis
Introduction
Stroke is a leading cause of morbidity and mortality worldwide.1 Cerebral reperfusion with mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) because of emergent large vessel occlusion.2, 3, 4, 5, 6, 7, 8, 9, 10 MT is effective across different patient subgroups including elderly patients, those who are ineligible for intravenous thrombolysis (IV tPA), and patients with tandem occlusions.6 Recent trials have demonstrated efficacy of MT in selected patients with delayed presentation of up to 24 hours postictus.11, 12
However, up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0–1 after MT.6 Failed MT may relate to thrombus burden, etiology, and/or endothelial injury during MT. Underlying intracranial atherosclerotic disease, particularly when associated with >70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. Recent observational studies suggest that this cohort of patients with failed and high failure risk MT may benefit from rescue stenting with more favorable clinical outcomes demonstrated after this treatment compared with medical management alone.13, 14, 15
The aims of this study were to systematically review the procedural and clinical outcomes in patients with failed and high failure risk MT, and to explore differences between patients receiving acute rescue stenting compared with medical management alone.
Section snippets
Literature Search Strategy
This study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.16, 17 A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications using Medical Subject Headings and general search terms from their date of inception until October 2018. The search strategy used a combination of the following terms: “stroke,” “middle cerebral
Search Strategy
A total of 4599 articles were identified through a comprehensive search of relevant databases. After removal of duplicates, 3344 articles were available for title and abstract screening. After removal of irrelevant articles based on title and abstract screening, 50 were retrieved for full-text analysis. Figure 1 outlines the search strategy following PRISMA guidelines, including reasons for exclusion after full-text review. Twelve studies were identified with a total of 530 patients who
Discussion
The results from this systematic review and meta-analysis suggest a significant benefit in clinical outcome to performing rescue stenting in patients with failed and high failure risk MT, without an increase in the rate of sICH, despite additional use of antiplatelet agents. There was also a numerically lower mortality in patients who received rescue stenting. Figure 5 demonstrates and highlights the use of intracranial angioplasty and stenting using the Wingspan device in a patient with a high
Conclusions
This meta-analysis suggests that rescue stenting is safe and efficacious in patients presenting with AIS in the setting of failed MT or with high-risk MT, with significant improvement in clinical outcomes and no corresponding risk of sICH. However, current data are limited to relatively small retrospective studies and should be cautiously interpreted. The data are not generalizable to all patients, given the variability in the underlying etiology of the failed MT therapy, and given the
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.