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A systematic review of the clinical effectiveness of emergency endovascular therapy using mechanical thrombectomy in acute ischaemic stroke: implications for service delivery

  • Ronan W. Glynn
  • Conor Teljeur
  • Joseph Harbison
  • David J. Williams
  • Patricia Harrington
  • Mairin Ryan
Original Article
  • 55 Downloads

Abstract

Background

Twelve randomised controlled trials (RCTs) comparing mechanical thrombectomy against traditional treatment options for patients experiencing acute ischaemic stroke (AIS) have been published.

Aims

To evaluate whether this technology is more effective and/or safer than traditional treatment options and to assess the potential for implementation of this technology as a treatment strategy for acute ischaemic stroke in Ireland.

Methods

RCTs published up to February 2017 were included. Meta-analysis was performed for two primary (mortality at 90 days, mRS at 90 days) and four secondary outcomes. Cumulative meta-analysis was used to investigate the point at which a consistent treatment effect was observed for outcomes that had a statistically significant pooled effect.

Results

Mechanical thrombectomy was associated with higher likelihood of being independent (mRS, p < 0.01; Barthel index, p < 0.01) at 90 days post-AIS (p < 0.001). Cumulative meta-analysis demonstrated a consistent treatment effect in favour of mechanical thrombectomy after each trial was added to the analysis. There was no evidence of a difference in mortality rates (p = 0.21) or rates of SICH (p = 0.71) between patients randomised to intervention and control arms. Although the intervention appears to be associated with higher rates of any cerebral haemorrhage (p < 0.01) and recurrent ischaemic stroke (p = 0.03), considerable uncertainty remains as to these treatment effects.

Conclusions

The trials published most recently have acted as a ‘watershed’ for mechanical thrombectomy, and while there are significant caveats, the data suggests that mechanical thrombectomy needs to be factored into the planning and delivery of services for the management of patients with acute ischaemic stroke in Ireland.

Keywords

Aspiration Endovascular Ischaemic stroke Meta-analysis Stent retriever Thrombectomy 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

11845_2018_1899_MOESM1_ESM.docx (619 kb)
ESM 1 (DOCX 618 kb)

References

  1. 1.
    Health in Ireland - Key trends. 2014, Department of Health and Children: DublinGoogle Scholar
  2. 2.
    Smyth B, et al. (2015) Planning for health: trends and priorities to inform health service planning 2016. Health Service Executive: DublinGoogle Scholar
  3. 3.
    Rha JH, Saver JL (2007) The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38(3):967–973CrossRefGoogle Scholar
  4. 4.
    Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste M, Koga M, von Kummer R, Lansberg M, Lindley RI, Murray G, Olivot JM, Parsons M, Tilley B, Toni D, Toyoda K, Wahlgren N, Wardlaw J, Whiteley W, del Zoppo G, Baigent C, Sandercock P, Hacke W, Stroke Thrombolysis Trialists’ Collaborative Group (2014) Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 384(9958):1929–1935CrossRefGoogle Scholar
  5. 5.
    Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, Feng L, Meyer BC, Olson S, Schwamm LH, Yoo AJ, Marshall RS, Meyers PM, Yavagal DR, Wintermark M, Guzy J, Starkman S, Saver JL, MR RESCUE Investigators (2013) A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 368(10):914–923CrossRefGoogle Scholar
  6. 6.
    Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, Silver FL, von Kummer R, Molina CA, Demaerschalk BM, Budzik R, Clark WM, Zaidat OO, Malisch TW, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Martin RH, Foster LD, Tomsick TA, Interventional Management of Stroke (IMS) III Investigators (2013) Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 368(10):893–903CrossRefGoogle Scholar
  7. 7.
    Ciccone A, Valvassori L (2013) Endovascular treatment for acute ischemic stroke. N Engl J Med 368(25):2433–2434Google Scholar
  8. 8.
    Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T, Guillemin F, THRACE investigators (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15(11):1138–1147CrossRefGoogle Scholar
  9. 9.
    Muir KW, Ford GA, Messow CM, Ford I, Murray A, Clifton A, Brown MM, Madigan J, Lenthall R, Robertson F, Dixit A, Cloud GC, Wardlaw J, Freeman J, White P, PISTE Investigators (2017) Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. J Neurol Neurosurg Psychiatry 88(1):38–44CrossRefGoogle Scholar
  10. 10.
    Mocco J, Zaidat OO, von Kummer R, Yoo AJ, Gupta R, Lopes D, Frei D, Shownkeen H, Budzik R, Ajani ZA, Grossman A, Altschul D, McDougall C, Blake L, Fitzsimmons BF, Yavagal D, Terry J, Farkas J, Lee SK, Baxter B, Wiesmann M, Knauth M, Heck D, Hussain S, Chiu D, Alexander MJ, Malisch T, Kirmani J, Miskolczi L, Khatri P, THERAPY Trial Investigators* (2016) Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone. Stroke 47(9):2331–2338CrossRefGoogle Scholar
  11. 11.
    Khoury NN, et al. (2017) Endovascular thrombectomy and medical therapy versus medical therapy alone in acute stroke: a randomized care trial. J NeuroradiolGoogle Scholar
  12. 12.
    Moher D et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4:1CrossRefGoogle Scholar
  13. 13.
    (2015) R: a language and environment for statistical computing. Available from: https://www.R-project.org/
  14. 14.
    Wiechtbauer W (2010) Conducting meta-analyses in R with the metafor package. J Stat Softw 36(3):1–48Google Scholar
  15. 15.
    Berkhemer OA, Fransen PS, Beumer D, van den Berg L, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen M, Staals J, Hofmeijer J, van Oostayen J, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk L, Kappelle LJ, Lo RH, van Dijk E, de Vries J, de Kort PL, van Rooij W, van den Berg J, van Hasselt B, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog H, Gerrits DG, van den Berg-Vos R, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam W, Roos YB, van der Lugt A, van Oostenbrugge R, Majoie CB, Dippel DW, MR CLEAN Investigators (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20CrossRefGoogle Scholar
  16. 16.
    Campbell BCV et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372(11):1009–1018CrossRefGoogle Scholar
  17. 17.
    Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A, REVASCAT Trial Investigators (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372(24):2296–2306CrossRefGoogle Scholar
  18. 18.
    Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R, SWIFT PRIME Investigators (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372(24):2285–2295CrossRefGoogle Scholar
  19. 19.
    Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD, ESCAPE Trial Investigators (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030CrossRefGoogle Scholar
  20. 20.
    Bassler D, Briel M, Montori VM, Lane M, Glasziou P, Zhou Q, Heels-Ansdell D, Walter SD, Guyatt GH, STOPIT-2 Study Group, Flynn DN, Elamin MB, Murad MH, Abu Elnour NO, Lampropulos JF, Sood A, Mullan RJ, Erwin PJ, Bankhead CR, Perera R, Ruiz Culebro C, You JJ, Mulla SM, Kaur J, Nerenberg KA, Schünemann H, Cook DJ, Lutz K, Ribic CM, Vale N, Malaga G, Akl EA, Ferreira-Gonzalez I, Alonso-Coello P, Urrutia G, Kunz R, Bucher HC, Nordmann AJ, Raatz H, da Silva SA, Tuche F, Strahm B, Djulbegovic B, Adhikari NK, Mills EJ, Gwadry-Sridhar F, Kirpalani H, Soares HP, Karanicolas PJ, Burns KE, Vandvik PO, Coto-Yglesias F, Chrispim PP, Ramsay T (2010) Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysis. Jama 303(12):1180–1187CrossRefGoogle Scholar
  21. 21.
    Campbell BCV, Donnan GA, Lees KR, Hacke W, Khatri P, Hill MD, Goyal M, Mitchell PJ, Saver JL, Diener HC, Davis SM (2015) Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke. Lancet Neurol 14(8):846–854CrossRefGoogle Scholar
  22. 22.
    Furlan AJ (2015) Endovascular therapy for stroke - it’s about time. N Engl J Med 372(24):2347–2349CrossRefGoogle Scholar
  23. 23.
    Goyal M, Menon BK, van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CBLM, van der Lugt A, de Miquel MA, Donnan GA, Roos YBWEM, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BCV, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731CrossRefGoogle Scholar
  24. 24.
    Pocock SJ, Stone GW (2016) The primary outcome is positive - is that good enough? N Engl J Med 375(10):971–979CrossRefGoogle Scholar
  25. 25.
    Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CBLM, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castaño C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro Á, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YBWEM, Hill MD, for the HERMES Collaborators (2016) Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. Jama 316(12):1279–1288CrossRefGoogle Scholar
  26. 26.
    Grossberg JA, Rebello LC, Haussen DC, Bouslama M, Bowen M, Barreira CM, Belagaje SR, Frankel MR, Nogueira RG (2018) Beyond large vessel occlusion strokes: distal occlusion thrombectomy. Stroke 49(7):1662–1668CrossRefGoogle Scholar
  27. 27.
    (2017) Health technology assessment of a national emergency endovascular service for mechanical thrombectomy in the management of acute ischaemic stroke. Health Information and Quality Authority: DublinGoogle Scholar
  28. 28.
    Motyer R, Kok HK, Asadi H, O'Hare A, Brennan P, Power S, Looby S, Nicholson P, Williams D, Murphy S, Hill MD, Goyal M, McManus J, O'Brien P, Thornton J (2017) Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset. J Intern Med 282(6):537–545CrossRefGoogle Scholar
  29. 29.
    McElwaine P, McCormack J, Harbison J, Irish Heart Foundation/HSE National Stroke Audit (2015) 2016, Irish Heart Foundation. Health Service Executive, DublinGoogle Scholar
  30. 30.
    McGee H (2010) Changing Cardiovascular Health. National Cardiovascular Health Policy 2010-2019. Department of Health and Children, DublinGoogle Scholar
  31. 31.
    Palaniswami M, Yan B (2015) Mechanical thrombectomy is now the gold standard for acute ischemic stroke: implications for routine clinical practice. Interv Neurol 4(1–2):18–29CrossRefGoogle Scholar
  32. 32.
    Acute Coronary Syndromes Programme. Model of Care. 2012: DublinGoogle Scholar
  33. 33.
    Hickey A, Horgan F, O'Neill D, McGee H, Steering Committee of the Irish National Audit of Stroke Care (INASC) (2012) Community-based post-stroke service provision and challenges: a national survey of managers and inter-disciplinary healthcare staff in Ireland. BMC Health Serv Res 12:111CrossRefGoogle Scholar
  34. 34.
    National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland (2011) Health Service Executive. Department of Health, DublinGoogle Scholar

Copyright information

© Royal Academy of Medicine in Ireland 2018

Authors and Affiliations

  1. 1.Health Technology Assessment DirectorateHealth Information and Quality AuthorityDublin 7Ireland
  2. 2.St. James’ HospitalDublinIreland
  3. 3.Geriatric MedicineRoyal College of Surgeons in Ireland (RCSI) and Beaumont HospitalDublinIreland

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