1. Patients in the thrombectomy group reported a greater independence in daily living compared to those receiving best medical therapy alone.

2. 90-day mortality did not differ between the thrombectomy and best medical therapy groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: There exists extensive evidence around the use of mechanical thrombectomy for patients with large vessel occlusion (LVO) strokes. However, whether clinical outcomes differ if treated within 6 hours of onset compared to between 6-24 hours is unknown. This systematic review and meta-analysis aimed to assess the safety and efficacy of thrombectomy versus best medical therapy in patients with anterior circulation LVO stroke. The primary outcome was reduced disability at 90 days, measured from 0-6 on the modified Rankin Scale (mRS), while key safety outcomes included intracerebral bleeding and death. According to study results, thrombectomy was superior to medical therapy for independence in activities of daily living, with no significant difference in 90-day mortality. In addition, there was a greater treatment effect seen in patients treated with thrombectomy in the 12-to-24-hour period compared to the 6-to-12-hour window. This study was strengthened by a systematic review design that collected individual patient data from a large sample of patients over many years, adding to the validity of findings. Overall, this study endorses the use of mechanical thrombectomy for reversal or cerebral ischemia within 6-24 hours of LVO stroke.

Click to read the study in The Lancet

Relevant Reading: Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke

In-depth [systematic review and meta-analysis]: This systematic review and meta-analysis included studies on endovascular therapy from Jan 1, 2010, to Mar 1, 2021. 505 patients (266 in thrombectomy group and 239 in the best medical therapy [alteplase] group) were included from six randomized controlled trials (RCTs). Mean patient age was 68.6 years (standard deviation [SD] 13.7) with the majority (n=259, 51.3%) being female. Patients were stratified by time from last well known (6-12h and 12-24h) and randomized to either group. The primary outcome of reduced disability at 90 days was in favor of thrombectomy (adjusted odds ratio [OR] 2.54, 95% confidence interval [CI] 1.83-3.54, p<0.0001) with a greater proportion of patients experiencing independence in activities of daily living (mRS 0-2) compared to medical therapy alone (45.9% vs. 19.3%, respectively; p<0.0001). In addition, a stronger treatment effect was noted in the 12-24 hour group (common OR 5.86, 95% CI 3.14-10.94) compared to 6-12 hours (common OR 1.76, 95% CI 1.18-2.62). However, there were no significant differences between thrombectomy and medical therapy regarding intracerebral hemorrhage (5.3% vs. 3.3%) and 90-day mortality (16.5% vs. 19.3%). Findings from this study suggest that endovascular thrombectomy may be done routinely in patients with LVO stroke across a 6-24h time window.

Image: PD

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