Endovascular Thrombectomy Alone versus Combined with Intravenous Thrombolysis

Kevin Phan, Adam A Dmytriw, Julian Maingard, Hamed Asadi, Christoph J Griessenauer, Wyatt Ng, Kitso Kewagamang, Ralph J Mobbs, Justin M Moore, Christopher S Ogilvy, Ajith J Thomas
World Neurosurgery 2017, 108: 850-858.e2

BACKGROUND: To date, no randomized trial has directly addressed the question of whether intravenous (IV) tissue plasminogen activator (tPA) improves outcomes in IV tPA-eligible patients who will eventually undergo endovascular therapy (EVT), or whether a direct EVT strategy is equally effective. We performed a systematic review and meta-analysis to compare the efficacy and safety of direct EVT versus endovascular treatment with IV tPA (EVT+IV tPA) in adults with acute ischemic stroke.

METHODS: We performed electronic searches of 6 databases from their inception to January 2017. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS: Twelve comparative studies, comprising 1275 patients in the EVT-only arm and 1340 patients in the combined EVT+IV tPA arm, were included. The rates of good functional outcomes (modified Rankin Scale score ≤2) and 90-day mortality were not statistically significantly different between the EVT and EVT+IV tPA arms (44% vs. 48%; odds ratio [OR], 0.80; 95% confidence interval [CI], 0.64-1.002; P = 0.052 and 20.4% vs. 19.4%, OR 1.19; 95% CI, 0.83-1.71; P = 0.34, respectively). The rate of symptomatic intracranial hemorrhage also was not significantly different between the EVT and EVT+IV tPA arms (3.7% vs. 3.8%; OR, 0.98; 95% CI, 0.65-1.48; P = 0.91). There were no between-group differences in the rates of other complications.

CONCLUSIONS: No significant differences between the 2 groups were found in terms of favorable functional outcome, mortality rate, or complications based on contemporary endovascular therapies.

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