Thrombectomy for the Treatment of Large Core Ischemic Strokes: An Updated Systematic Review and Meta-analysis After the Release of the TESLA and TENSION Trials
Mahmoud Dibas1, Mohammad Almajali2, Malik Ghannam1, Milagros Galecio-Castillo1, Abdullah Al Qudah3, Farid Khasiyev4, Juan Vivanco-Suarez5, Aaron Rodriguez Calienes1, Sophie Shogren6, Fawaz Al Majali7, Albert Yoo8, Edgar Samaniego2, Amrou Sarraj9, Santiago Ortega Gutierrez10
1Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA, 2University of Iowa Hospital and Clinics, 3Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 4Department of Neurology, Saint Louis University, Saint Louis, MO, USA, 5Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, US, 6University of Iowa Hospitals and Clinics, 7Department of General Surgery, Saint Louis University, Saint Louis, MO, US, 8Texas Stroke Institute, 9Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, US, 10University of Iowa
Objective:
This study aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) in large-core acute ischemic stroke (AIS) patients
Background:
The available evidence supporting the use of EVT in patients with large-core AIS is increasing. Recently, the results of the TESLA and TENSION trials were released. This calls for an updated systematic review and meta-analysis that combines these studies with the prior results of previously published trials
Design/Methods:
A systematic review was conducted to include randomized controlled trials (RCTs) that compared EVT to medical management (MM) for the treatment of patients with large-core AIS. The outcomes included the modified Rankin Scale (mRS) and mortality at 90 days and rates of symptomatic intracranial hemorrhage (sICH). An mRS of 0-2 and 0-3 were used to define independent and moderate functional status, respectively. Pooled odds ratios (OR) were calculated for shift mRS through the random-effects meta-analyses, while risk ratios (RR) were used for the other outcomes, comparing EVT with MM alone
Results:
Out of 2105 documents from title and abstract screening, this study included five RCTs. The odds for a shift to better mRS was higher in the EVT group as compared to the MM alone (OR: 1.46, 95%CI: 1.19-1.79). Furthermore, the use of EVT was associated with more instances of independent (RR: 2.47, 95%CI: 1.87-3.25) and moderate (RR: 1.77, 95%CI: 1.41-2.24) functional status as compared to MM. The rates of sICH were higher in the EVT group (RR: 1.73, 95%CI: 1.01-2.95) than the MM, but there was no difference between the two groups regarding mortality (RR: 0.92, 95%CI: 0.8-1.06). Subgroup analyses based on age, location, window, NIHSS, ASPECTS, core-volume, thrombolysis, and etiology did not yield group differences
Conclusions:
Our results confirm the efficacy and safety of EVT for large-core AIS. Identifying patients that might not benefit from EVT need to be studied further.