School of Public Health (W.H., J.H., H.L., Y.H.), Capital Medical University, Beijing, China.
Department of Neurology, Xuanwu Hospital (C.W., W.Z.), Capital Medical University, Beijing, China.
Stroke. 2020 Jul;51(7):2026-2035. doi: 10.1161/STROKEAHA.119.028624. Epub 2020 Jun 3.
The optimal recanalization strategy for acute ischemic stroke with large vessel occlusion continues to be an area of active interest. Network meta-analysis can provide insight when direct comparative evidence is lacking.
A systematic review of the literature using PubMed, Embase, the Cochrane Central Register of Controlled Trials, and SinoMed was performed, and a search was conducted for clinical trials on ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and StrokeCenter.org. Four independent reviewers conducted the study selection, data abstraction, and quality assessments.
The literature review identified 17 trials including 3236 patients and 8 ongoing clinical trials. Sample sizes ranged from 7 to 656 participants. Intravenous thrombolysis (IVT) was the most common intervention, followed by IVT plus mechanical thrombectomy (MT), IVT plus intraarterial thrombolysis, intraarterial thrombolysis alone, and MT alone. In the pooled network meta-analysis, IVT+MT was associated with a higher rate of independent functioning. In contrast, IVT was ranked as the most ineffective treatment strategy with respect to neurological functions, while direct MT was ranked as the least safe intervention with respect to all-cause mortality. Also, irrespective of assessment tools, endovascular treatment plus IVT led to higher successful recanalization rate than thrombolysis alone.
Compared with other recanalization treatments, IVT+MT seems to be the most effective strategy, without increasing detrimental effects, for thrombolysis-eligible patients with large vessel occlusion-acute ischemic stroke. To improve the current evidentiary basis for recanalization treatment, future trials and real-world studies are warranted and should use unified definitions of symptomatic intracranial hemorrhage and recanalization.
对于伴有大血管闭塞的急性缺血性脑卒中，其最佳再通策略仍然是一个活跃的研究领域。当缺乏直接比较证据时，网络荟萃分析可以提供深入的见解。
我们对PubMed、Embase、Cochrane 中央对照试验注册库和中国生物医学文献数据库进行了系统的文献检索，并在 ClinicalTrials.gov、世界卫生组织国际临床试验注册平台和 StrokeCenter.org 上对临床试验进行了搜索。四名独立的评审员进行了研究选择、数据提取和质量评估。
文献综述共确定了 17 项试验，包括 3236 名患者和 8 项正在进行的临床试验。样本量从 7 到 656 名参与者不等。静脉溶栓（IVT）是最常见的干预措施，其次是 IVT 加机械血栓切除术（MT）、IVT 加动脉内溶栓、单纯动脉内溶栓和 MT 加 IVT。在汇总的网络荟萃分析中，IVT+MT 与更高的独立功能率相关。相比之下，IVT 在神经功能方面被认为是最无效的治疗策略，而直接 MT 在全因死亡率方面被认为是最不安全的干预措施。此外，无论评估工具如何，血管内治疗加 IVT 导致的再通率均高于单独溶栓。
与其他再通治疗方法相比，对于大血管闭塞性急性缺血性脑卒中的溶栓合格患者，IVT+MT 似乎是最有效的策略，不会增加有害影响。为了改善目前再通治疗的证据基础，未来的试验和真实世界研究是必要的，并且应该使用统一的症状性颅内出血和再通定义。
