Phan Kevin, Dmytriw Adam A, Maingard Julian, Asadi Hamed, Griessenauer Christoph J, Ng Wyatt, Kewagamang Kitso, Mobbs Ralph J, Moore Justin M, Ogilvy Christopher S, Thomas Ajith J
NeuroSpine Surgery Research Group, Sydney, Australia.
Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
World Neurosurg. 2017 Dec;108:850-858.e2. doi: 10.1016/j.wneu.2017.08.040. Epub 2017 Aug 18.
To date, no randomized trial has directly addressed the question of whether intravenous (IV) tissue plasminogen activator (tPA) improves outcomes in IV tPA-eligible patients who will eventually undergo endovascular therapy (EVT), or whether a direct EVT strategy is equally effective. We performed a systematic review and meta-analysis to compare the efficacy and safety of direct EVT versus endovascular treatment with IV tPA (EVT+IV tPA) in adults with acute ischemic stroke.
We performed electronic searches of 6 databases from their inception to January 2017. Data were extracted and analyzed according to predefined clinical endpoints.
Twelve comparative studies, comprising 1275 patients in the EVT-only arm and 1340 patients in the combined EVT+IV tPA arm, were included. The rates of good functional outcomes (modified Rankin Scale score ≤2) and 90-day mortality were not statistically significantly different between the EVT and EVT+IV tPA arms (44% vs. 48%; odds ratio [OR], 0.80; 95% confidence interval [CI], 0.64-1.002; P = 0.052 and 20.4% vs. 19.4%, OR 1.19; 95% CI, 0.83-1.71; P = 0.34, respectively). The rate of symptomatic intracranial hemorrhage also was not significantly different between the EVT and EVT+IV tPA arms (3.7% vs. 3.8%; OR, 0.98; 95% CI, 0.65-1.48; P = 0.91). There were no between-group differences in the rates of other complications.
No significant differences between the 2 groups were found in terms of favorable functional outcome, mortality rate, or complications based on contemporary endovascular therapies.
迄今为止，尚无随机试验直接探讨静脉注射组织型纤溶酶原激活剂（tPA）是否能改善最终将接受血管内治疗（EVT）的符合静脉注射tPA条件的患者的预后，或者直接EVT策略是否同样有效。我们进行了一项系统评价和荟萃分析，以比较直接EVT与静脉注射tPA的血管内治疗（EVT + IV tPA）在急性缺血性脑卒中成人患者中的疗效和安全性。
我们对6个数据库从创建至2017年1月进行了电子检索。根据预定义的临床终点提取并分析数据。
纳入了12项比较研究，其中单纯EVT组有1275例患者，EVT + IV tPA联合组有1340例患者。EVT组和EVT + IV tPA组之间的良好功能预后（改良Rankin量表评分≤2）率和90天死亡率无统计学显著差异（44%对48%；优势比[OR]，0.80；95%置信区间[CI]，0.64 - 1.002；P = 0.052）以及（20.4%对19.4%，OR 1.19；95% CI，0.83 - 1.71；P = 0.34）。症状性颅内出血率在EVT组和EVT + IV tPA组之间也无显著差异（3.7%对3.8%；OR，0.98；95% CI，0.65 - 1.48；P = 0.91）。其他并发症发生率在组间无差异。
基于当代血管内治疗，两组在良好功能预后、死亡率或并发症方面未发现显著差异。
