Nam Julian, Jing He, O'Reilly Daria
Department of Clinical Epidemiology and Biostatistics, Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada.
Int J Stroke. 2015 Jan;10(1):13-22. doi: 10.1111/j.1747-4949.2012.00914.x. Epub 2013 Jan 7.
Recent evidence has suggested that intra-arterial thrombolysis may provide benefit beyond intravenous thrombolysis in ischemic stroke patients. Previous meta-analyses have only compared intra-arterial thrombolysis with standard treatment without thrombolysis. The objective was to review the benefits and harms of intra-arterial thrombolysis in ischemic stroke patients.
We undertook a meta-analysis of randomized controlled trials comparing the efficacy and safety of intra-arterial thrombolysis with either standard treatment or intravenous thrombolysis following acute ischemic stroke. Primary outcomes included poor functional outcomes (modified Rankin Scale 3-6), mortality, and symptomatic intracranial hemorrhage. Study quality was assessed, and outcomes were stratified by comparison treatment received.
Four trials (n = 351) comparing intra-arterial thrombolysis with standard treatment were identified. Intra-arterial thrombolysis reduced the risk of poor functional outcomes (modified Rankin Scale 3-6) [relative risk (RR) = 0·80; 95% confidence interval = 0·67-0·95; P = 0·01]. Mortality was not increased (RR = 0·82; 95% confidence interval = 0·56-1·21; P = 0·32); however, risk of symptomatic intracranial hemorrhage was nearly four times more likely (RR = 3·90; 95% confidence interval = 1·41-10·76; P = 0·006). Two trials (n = 81) comparing intra-arterial thrombolysis with intravenous thrombolysis were identified. Intra-arterial thrombolysis was not found to reduce poor functional outcomes (modified Rankin Scale 3-6) (RR = 0·68; 95% confidence interval = 0·46-1·00; P = 0·05). Mortality was not increased (RR = 1·12; 95% confidence interval = 0·47-2·68; P = 0·79); neither was symptomatic intracranial hemorrhage (RR = 1·13; 95% confidence interval = 0·32-3·99; P = 0·85). Differences in time from symptom onset-to-treatment and type of thrombolytic administered were found across the trials.
This analysis finds a modest benefit of intra-arterial thrombolysis over standard treatment, although it does not find a clear benefit of intra-arterial thrombolysis over intravenous thrombolysis in acute ischemic stroke patients. However, few trials, small sample sizes, and indirectness limit the strength of evidence.
近期证据表明，对于缺血性脑卒中患者，动脉内溶栓可能比静脉溶栓更有益。以往的荟萃分析仅将动脉内溶栓与未进行溶栓的标准治疗进行了比较。目的是评估动脉内溶栓对缺血性脑卒中患者的益处和危害。
我们对随机对照试验进行了荟萃分析，比较急性缺血性脑卒中后动脉内溶栓与标准治疗或静脉溶栓的疗效和安全性。主要结局包括功能预后不良（改良Rankin量表评分为3 - 6分）、死亡率和症状性颅内出血。评估了研究质量，并根据接受的对照治疗对结局进行分层。
确定了4项（n = 351）比较动脉内溶栓与标准治疗的试验。动脉内溶栓降低了功能预后不良（改良Rankin量表评分为3 - 6分）的风险[相对危险度（RR）= 0.80；95%置信区间 = 0.67 - 0.95；P = 0.01]。死亡率未增加（RR = 0.82；95%置信区间 = 0.56 - 1.21；P = 0.32）；然而，症状性颅内出血的风险增加了近四倍（RR = 3.90；95%置信区间 = 1.41 - 10.76；P = 0.006）。确定了2项（n = 81）比较动脉内溶栓与静脉溶栓的试验。未发现动脉内溶栓能降低功能预后不良（改良Rankin量表评分为3 - 6分）的风险（RR = 0.68；95%置信区间 = 0.46 - 1.00；P = 0.05）。死亡率未增加（RR = 1.12；95%置信区间 = 0.47 - 2.68；P = 0.79）；症状性颅内出血也未增加（RR = 1.13；95%置信区间 = 0.32 - 3.99；P = 0.85）。各试验在症状发作至治疗的时间以及所给予溶栓药物的类型方面存在差异。
该分析发现动脉内溶栓相对于标准治疗有一定益处，尽管在急性缺血性脑卒中患者中未发现动脉内溶栓相对于静脉溶栓有明显益处。然而，试验数量少、样本量小以及间接性限制了证据的强度。
