Second Department of Neurology, 'Attikon' University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
J Neurol Neurosurg Psychiatry. 2023 Oct;94(10):781-785. doi: 10.1136/jnnp-2023-331513. Epub 2023 Jul 14.
Current guidelines recommend endovascular treatment (EVT) for acute ischaemic stroke (AIS), due to large-vessel occlusion and an Alberta Stroke Program Early CT Score (ASPECTS) of ≥6. High-quality evidence resulting from randomised controlled clinical trials (RCTs) regarding EVT among large-core AIS has recently become available, justifying an updated meta-analysis aiming to evaluate efficacy and safety of EVT in this clinical setting.
We conducted a systematic review and meta-analysis including all available RCTs that compared EVT in addition to best medical treatment (BMT) versus BMT alone for large-core AIS (defined by ASPECTS 2-5 or volumetric methods). The primary outcome was reduced disability at 3 months (≥1-point reduction across all Modified Rankin Scale (mRS) grades). Secondary outcomes included independent ambulation at 3 months (mRS score 0-3), good functional outcome at 3 months (mRS score 0-2), excellent functional outcome at 3 months (mRS score 0-1), symptomatic intracranial haemorrhage (sICH) and any intracranial haemorrhage (ICH) and mortality at 3 months. The random-effects model was used.
Four RCTs were included comprising a total of 662 patients treated with EVT vs 649 patients treated with BMT. Compared with BMT, EVT was significantly associated with reduced disability (common OR 1.70, 95% CI 1.39 to 2.07; I=0%), independent ambulation (risk ratio (RR) 1.69, 95% CI 1.33 to 2.14; I=39%) and good functional outcome (RR 2.33, 95% CI 1.76 to 3.10; I=0%), but not with excellent functional outcome (RR 1.46, 95% CI 0.91 to 2.33; I=39%) at 3 months. Although rates of sICH (RR 1.98, 95% CI 1.07 to 3.68; I=0%) and any ICH (RR 2.13, 95% CI 1.70 to 2.66; I=37%) were higher in the EVT group, 3-month mortality (RR 0.98, 95% CI 0.83 to 1.15; I=0%) did not differ between the two groups.
EVT appears to be effective and safe and may be considered for the treatment of large-core AIS, as assessed by ASPECTS of 2-5 or volumetric methods.
CRD42022334417.
目前的指南建议对急性缺血性脑卒中（AIS）进行血管内治疗（EVT），因为存在大血管闭塞和 Alberta 卒中项目早期 CT 评分（ASPECTS）≥6。最近，大型核心 AIS 中 EVT 的随机对照临床试验（RCT）产生了高质量的证据，这证明了进行旨在评估该临床环境中 EVT 的疗效和安全性的更新荟萃分析是合理的。
我们进行了一项系统评价和荟萃分析，纳入了所有比较 EVT 加最佳药物治疗（BMT）与单独 BMT 治疗大型核心 AIS（定义为 ASPECTS 2-5 或容积方法）的 RCT。主要结局为 3 个月时残疾程度降低（所有改良 Rankin 量表（mRS）等级降低≥1 分）。次要结局包括 3 个月时独立行走（mRS 评分 0-3）、3 个月时功能良好（mRS 评分 0-2）、3 个月时功能良好（mRS 评分 0-1）、症状性颅内出血（sICH）和任何颅内出血（ICH）和 3 个月时的死亡率。使用随机效应模型。
共纳入四项 RCT，共计 662 例 EVT 治疗患者和 649 例 BMT 治疗患者。与 BMT 相比，EVT 显著降低残疾（常见比值比 1.70，95%置信区间 1.39 至 2.07；I=0%）、独立行走（风险比（RR）1.69，95%置信区间 1.33 至 2.14；I=39%）和良好的功能结局（RR 2.33，95%置信区间 1.76 至 3.10；I=0%），但 3 个月时的优秀功能结局（RR 1.46，95%置信区间 0.91 至 2.33；I=39%）没有差异。尽管 EVT 组的 sICH（RR 1.98，95%置信区间 1.07 至 3.68；I=0%）和任何 ICH（RR 2.13，95%置信区间 1.70 至 2.66；I=37%）的发生率较高，但两组 3 个月时的死亡率（RR 0.98，95%置信区间 0.83 至 1.15；I=0%）没有差异。
根据 ASPECTS 为 2-5 或容积方法评估，EVT 似乎有效且安全，可考虑用于治疗大型核心 AIS。
PROSPERO 注册号：CRD42022334417。
