Endovascular intervention shows better outcomes than standard stroke treatment

by Bruce Sylvester: Results from a meta-analysis of randomized trials for the treatment of acute ischemic stroke suggest that, compared to standard clot dissolving treatment, endovascular intervention, such as clot removal by catheter, produced better functional outcomes and higher rates of functional independence at 90 days.

However, there was no significant difference in symptomatic intracranial hemorrhage or all-cause mortality.

The investigators reported the findings on November 3, 2015 in JAMA, the Journal of the American Medical Association.

“Among patients with acute ischemic stroke, endovascular therapy with mechanical thrombectomy vs standard medical care with tPA [tissue plasminogen activator] was associated with improved functional outcomes and higher rates of angiographic revascularization, but no significant difference in symptomatic intracranial hemorrhage or all-cause mortality at 90 days,” the authors wrote

As background, the authors noted that about 10 percent of patients presenting with ischemic stroke are eligible for treatment with intravenous tPA. This clinical situation has led to interest in endovascular therapy for acute ischemic stroke.

Saleh A. Almenawer, M.D., of McMaster University, Hamilton, Ontario, Canada, and colleagues conducted a meta-analysis of data from 8 trials involving 2,423 patients with acute ischemic stroke. Average age was 67 years and 47 percent were women.

The analysis included data on 1,313 subjects who underwent endovascular thrombectomy and 1,110 who received standard medical care with tPA.

Endovascular therapy was defined and limited to intra-arterial use of a microcatheter or other device for mechanical thrombectomy (clot removal) with or without the use of a clot dissolving agent.

Compared to standard intervention, endovascular therapy showed a statistically significant treatment benefit for measures of functional outcomes. Functional independence at 90 days appeared among 557 of 1293 patients (44.6%) in the endovascular therapy group versus 351 of 1094 patients (31.8%) in the standard medical care group (p = .005).

Compared with standard care, endovascular thrombectomy associated with statistically significantly higher rates of angiographic revascularization at 24 hours (75.8% versus 34.1%, p < .001) but no significant difference in rates of symptomatic intracranial hemorrhage within 90 days (70 events [5.7%] versus 53 events [5.1%], p = .56) or all-cause mortality at 90 days (218 deaths [15.8%] versus 201 deaths [17.8%], p = .27).

“This meta-analysis synthesizes evidence from multicenter randomized clinical trials, and may help inform the design and execution of future studies examining the efficacy of endovascular therapy for acute ischemic stroke. Additional trials are needed to systematically study the relationship of patient-, disease-, and treatment-related variables with outcomes following mechanical thrombectomy, and to identify the ideal patient to undergo endovascular therapy,” the authors said.