This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
Abstract
Objective To provide a critical appraisal on the evidence from randomized controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by IV thrombolysis (bridging therapy [BT]) for patients with acute large vessel occlusion (LVO).
Methods Eligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (CIs) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0 to 2 at 3 months.
Results We included 3 studies comprising 1,092 patients. No difference between the dEVT and BT groups was detected for the outcomes of mRS score of 0 to 2 (OR 1.08, 95% CI 0.85–1.38; adjusted OR 1.11, 95% CI 0.76–1.63), mRS score of 0 to 1 (OR 1.10, 95% CI 0.84–1.43; adjusted OR 1.16, 95% CI 0.84–1.61), and functional improvement at 3 months (common OR 1.08, 95% CI 0.88–1.34; adjusted common OR 1.09, 95% CI 0.86–1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization before the endovascular procedure compared to those receiving BT (OR 0.37, 95% CI 0.18–0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR 0.67, 95% CI 0.49–0.92) but without a significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events, or procedural complications between the 2 groups were uncovered.
Conclusions We detected no differences in functional outcomes of IV thrombolysis–eligible patients with an acute LVO receiving dEVT compared to BT. Because uncertainty for most endpoints remains large and the available data are not able to exclude the possibility of overall benefit or harm, further RCTs are needed.
Glossary
- AIS=
- acute ischemic stroke;
- BT=
- bridging therapy;
- CI=
- confidence interval;
- dEVT=
- direct endovascular thrombectomy;
- DEVT=
- Direct Endovascular Therapy Trial;
- DIRECT-MT=
- Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals;
- DIRECT-SAFE=
- A Randomized Controlled Trial of Direct Endovascular Clot Retrieval Versus Standard Bridging Thrombolysis With Endovascular Clot Retrieval;
- ICH=
- intracranial hemorrhage;
- IVT=
- IV thrombolysis;
- LVO=
- large vessel occlusion;
- mRS=
- modified Rankin Scale;
- NNH=
- number needed to harm;
- NNT=
- number needed to treat;
- OR=
- odds ratio;
- RCT=
- randomized controlled clinical trial;
- SKIP=
- Randomized Study of EVT With Versus Without Intravenous Recombinant Tissue-Type Plasminogen Activator in Acute Stroke With ICA and M1 Occlusion;
- SWIFT-DIRECT=
- Bridging Thrombolysis Versus Direct Mechanical Thrombectomy in Acute Ischemic Stroke
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received February 8, 2021.
- Accepted in final form May 24, 2021.
- © 2021 American Academy of Neurology
AAN Members
We have changed the login procedure to improve access between AAN.com and the Neurology journals. If you are experiencing issues, please log out of AAN.com and clear history and cookies. (For instructions by browser, please click the instruction pages below). After clearing, choose preferred Journal and select login for AAN Members. You will be redirected to a login page where you can log in with your AAN ID number and password. When you are returned to the Journal, your name should appear at the top right of the page.
AAN Non-Member Subscribers
Purchase access
Letters: Rapid online correspondence
REQUIREMENTS
You must ensure that your Disclosures have been updated within the previous six months. Please go to our Submission Site to add or update your Disclosure information.
Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.
If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.
Submission specifications:
- Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
- Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
- Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- Submitted comments are subject to editing and editor review prior to posting.
You May Also be Interested in
Topics Discussed
Alert Me
Recommended articles
Clinical and Neuroimaging Outcomes of Direct Thrombectomy vs Bridging Therapy in Large Vessel Occlusion
Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion
Endovascular vs medical management of acute ischemic stroke
Outcome of endovascular therapy in stroke with large vessel occlusion and mild symptoms