Palaiodimou Lina, Eleftheriou Andreas, Katsanos Aristeidis H, Safouris Apostolos, Magoufis Georgios, Spiliopoulos Stavros, Velonakis Georgios, Vassilopoulou Sofia, de Sousa Diana Aguiar, Turc Guillaume, Strbian Daniel, Tsivgoulis Georgios
Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 15784 Athens, Greece.
Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON L8L2X2, Canada.
J Clin Med. 2023 Mar 30;12(7):2617. doi: 10.3390/jcm12072617.
High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs).
We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest.
Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16-2.05; I = 60%), functional independence (RR: 1.83; 95% CI: 1.08-3.08; I = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26-3.05; I = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36-25.61; I = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50-5.44; I = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65-0.89; I = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China.
EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight.
近期完成的随机对照临床试验（RCT）提供了关于急性基底动脉闭塞（BAO）患者血管内治疗（EVT）应用的高质量证据。
我们进行了一项系统评价和荟萃分析，纳入了所有可用的RCT，这些研究调查了EVT联合最佳药物治疗（BMT）与单纯BMT治疗BAO的疗效和安全性。采用随机效应模型，同时针对感兴趣的二分结局计算脆弱性指数（FI）。
纳入了4项RCT，共988例急性BAO患者（平均年龄：65.6岁，70%为男性，美国国立卫生研究院卒中量表[NIHSS]中位数：24，39%在治疗前接受过静脉溶栓）。与单纯BMT相比，EVT与更好的功能结局可能性更高（风险比[RR]：1.54；95%置信区间[CI]：1.16 - 2.05；I² = 60%）、功能独立性更高（RR：1.83；95% CI：1.08 - 3.08；I² = 79%）以及3个月时残疾程度降低相关（校正后的共同比值比[OR]：1.96；95% CI：1.26 - 3.05；I² = 59%）。尽管EVT与症状性颅内出血风险更高（RR：7.78；95% CI：2.36 - 25.61；I² = 0%）和任何颅内出血风险更高（RR：2.85；95% CI：1.50 - 5.44；I² = 16%）相关，但接受EVT联合BMT的患者3个月时的死亡率低于单纯接受BMT的患者（RR：0.76；95% CI：0.65 - 0.89；I² = 0%）。然而，在任何已报道的关联中（FI < 10），包括关于主要结局的总体效应，均未显示出足够的稳健性。前者的关联主要由在中国进行的招募受限的RCT驱动。
与单纯BMT相比，EVT联合BMT与3个月时获得更好功能结局的可能性更高以及死亡风险更低相关，尽管症状性颅内出血风险更高。有必要进行个体患者数据荟萃分析，以发现并调整潜在的异质性来源，并提供进一步的见解。
