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Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis of Stent Retrievers vs Direct Aspiration vs a Combined Approach.

Authors
  • Texakalidis, Pavlos1
  • Giannopoulos, Stefanos2
  • Karasavvidis, Theofilos3
  • Rangel-Castilla, Leonardo4
  • Rivet, Dennis J5
  • Reavey-Cantwell, John5
  • 1 Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia. , (Georgia)
  • 2 Department of Vascular Surgery, 251 HAF and VA Hospital, Athens, Greece. , (Greece)
  • 3 Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece. , (Greece)
  • 4 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.
  • 5 Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia.
Type
Published Article
Journal
Neurosurgery
Publication Date
Apr 01, 2020
Volume
86
Issue
4
Pages
464–477
Identifiers
DOI: 10.1093/neuros/nyz258
PMID: 31313819
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke due to a large vessel occlusion. To compare the safety and efficacy profile of the different mechanical thrombectomy strategies. A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Nineteen studies with a total of 2449 patients were included. No differences were identified between the stent retrieval and direct aspiration groups in terms of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 and mTICI 3 recanalization rates, and favorable outcomes (modified Rankin Scale [mRS] ≤ 2). Adverse event rates, including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH), were similar between the stent retrieval and direct aspiration groups. The use of the stent retrieval was associated with a higher risk of vasospasm (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.10-8.09; I2: 0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.47; 95% CI: 1.02-2.12; I2: 0%) and mTICI 3 recanalization (OR: 3.65; 95% CI: 1.56-8.54), although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32). Stent retrieval thrombectomy and direct aspiration did not show significant differences. Current available evidence is not sufficient to draw conclusions on the best surgical approach. The combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates, although with a higher risk of 24-h SAH, when compared with direct aspiration. Copyright © 2019 by the Congress of Neurological Surgeons.

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