Tsivgoulis Georgios, Katsanos Aristeidis H, Mavridis Dimitris, Alexandrov Anne W, Magoufis Georgios, Arthur Adam, Caso Valeria, Schellinger Peter D, Alexandrov Andrei V
Second Department of Neurology, Attikon University General Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, Athens, 15344, Greece.
Second Department of Neurology, Attikon University General Hospital, School of Medicine, University of Athens, Athens, Greece Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece.
Ther Adv Neurol Disord. 2017 Mar;10(3):151-160. doi: 10.1177/1756285616680549. Epub 2016 Dec 1.
Current recommendations advocate that pretreatment with intravenous thrombolysis (IVT) should first be offered to all eligible patients with emergent large vessel occlusion (ELVO) before an endovascular thrombectomy (ET) procedure. However, there are observational data that question the safety and efficacy of IVT pretreatment in patients with ELVO.
We performed a meta-analysis of the included subgroups from ET randomized controlled trials (RCTs) to evaluate the comparative efficacy between direct ET without IVT pretreatment and bridging therapy (IVT and ET) in patients with ELVO.
We included a total of seven RCTs, including 1764 patients with ELVO (52.8% men). Patients receiving bridging therapy (IVT followed by ET) had lower rates ( = 0.041) of 90-day death/severe dependency (modified Rankin Scale-score of 5-6; 19.0%, 95% CI: 14.1-25.1%) compared with patients receiving only ET (31.0%, 95% CI: 21.2-42.9%). Moreover, patients receiving IVT and ET had a nonsignificant ( = 0.389) trend towards higher 90-day functional independence rates (51.4%, 95% CI: 42.5-60.1%) compared with patients undergoing only ET (41.7%, 95% CI: 24.1-61.7%). Finally, shift-analysis uncovered a nonsignificant trend towards functional improvement at 90 days for bridging therapy over ET (cOR = 1.28, 95% CI: 0.91-1.89; = 0.155). It should be noted that patients included in the present meta-analysis were not randomized to receive IVT, and thus the two groups (bridging therapy ET monotherapy) may differ in terms of baseline characteristics and, in particular, in terms of onset to groin puncture time and thus the risk of confounding bias cannot be ruled out.
Despite the limitations and the risk of confounding bias, our findings contradict the recent notion regarding potential equality between ET and bridging therapy in ELVO patients and suggest that IVT and ET are complementary therapies that should be pursued in a parallel and noncompeting fashion.
当前建议主张，对于所有符合条件的急性大血管闭塞（ELVO）患者，在进行血管内血栓切除术（ET）之前，应首先给予静脉溶栓（IVT）预处理。然而，有观察数据对ELVO患者IVT预处理的安全性和有效性提出质疑。
我们对ET随机对照试验（RCT）纳入的亚组进行了荟萃分析，以评估未进行IVT预处理的直接ET与桥接治疗（IVT和ET）在ELVO患者中的疗效比较。
我们共纳入了7项RCT，包括1764例ELVO患者（男性占52.8%）。与仅接受ET的患者（31.0%，95%CI：21.2 - 42.9%）相比，接受桥接治疗（IVT后进行ET）的患者90天死亡/严重依赖（改良Rankin量表评分5 - 6分）发生率较低（P = 0.041；19.0%，95%CI：14.1 - 25.1%）。此外，与仅接受ET的患者（41.7%，95%CI：24.1 - 61.7%）相比，接受IVT和ET的患者90天功能独立率有升高趋势，但差异无统计学意义（P = 0.389；51.4%，95%CI：42.5 - 60.1%）。最后，转换分析发现桥接治疗在90天时功能改善趋势优于ET，但差异无统计学意义（cOR = 1.28，95%CI：0.91 - 1.89；P = 0.155）。需要注意的是，本荟萃分析纳入的患者并非随机接受IVT，因此两组（桥接治疗与ET单药治疗）在基线特征方面可能存在差异，尤其是在发病至股动脉穿刺时间方面，因此不能排除混杂偏倚的风险。
尽管存在局限性和混杂偏倚风险，但我们的研究结果与近期关于ELVO患者中ET与桥接治疗可能等效的观点相矛盾，表明IVT和ET是互补的治疗方法，应以并行且不相互竞争的方式进行。
