Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke

1. Compared to patients treated with medical therapy alone, patients with an ischemic stroke undergoing endovascular thrombectomy combined with medical therapy had lower rates of disability 3 months after their stroke.

2. Utilizing thrombectomy up to 7.3 hours after the onset of symptoms of ischemic stroke was associated with improved outcomes.

Evidence Rating Level: 2 (Good)

Study Rundown: While the clinical benefit of endovascular thrombectomy has been established for patients with an ischemic stroke, there remains uncertainty around its relative benefit compared to medical therapies and the timing of the intervention. This multi-centered meta-analysis reviewed the results of 5 randomized control trials comparing patients who received either endovascular thrombectomy and medical therapy, or medical therapy alone. The primary outcome analyzed the degree of disability at 3 months, while secondary measures included functional independence and mortality at 3 months. The results showed that patients who received endovascular thrombectomy plus medical therapy experienced less disability although the odds of more severe disability increased with longer times between the onset of symptoms and arterial puncture. Patients who had substantial reperfusion after endovascular thrombectomy also experienced greater disability with each hour delay to reperfusion. There was no difference in mortality between those who received endovascular thrombectomy and medical therapy vs. medical therapy alone.

This study helps to refine the guidelines around the timing of care among patients with ischemic stroke undergoing endovascular thrombectomy. However, there was no strict inclusion and exclusion criteria for patient characteristics, raising the possibility of potential bias, and longer follow-ups of functional status were not recorded. Overall though, this study suggests that endovascular thrombectomy with medical therapy is beneficial in acute stroke patients with large vessel occlusions.

Click to read the study in JAMA

Relevant Reading: Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.

In-Depth [meta-analysis]: This meta-analysis and systematic review evaluated acute stroke patients with large vessel occlusions to determine whether there was a significant benefit of endovascular thrombectomy and medical therapy compared to medical therapy alone. It included 5 randomized controlled trials from multiple centers across North America and Europe. Patients had acute large vessel stroke and were classified as receiving either an endovascular intervention with medical therapy or medical therapy alone. The primary outcome measure was the degree of disability at 3 months, measured on the modified Rankin Scale. Furthermore, functional independence and mortality at 3 months was also evaluated.

In the study, 1287 patients in total were included. 634 received endovascular thrombectomy along with medical therapy and 653 patients received medical therapy alone. Endovascular thrombectomy was associated with a significantly lower degree of disability at 3 months (mRS = 2.9, 95%CI 2.7-3.1; vs. 3.6, 95%CI 3.5-3.8 in the medical therapy group). The degree of benefit from endovascular thrombectomy declined in a step-wise fashion with longer durations from symptom onset to arterial puncture (3 hours: cOR 2.79, 95%CI 1.96-3.98; 6 hours: cOR 1.98, 95%CI 1.30-3.00; 8 hours: cOR 1.57, 95%CI 0.86-2.88). The odds of functional independence declined in a similar manner.

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