Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data
Por:
Roman, LS, Menon, BK, Blasco, J, Hernandez-Perez, M, Davalos, A, Majoie, CBLM, Campbell, BCV, Guillemin, F, Lingsma, H, Anxionnat, R, Epstein, J, Saver, JL, Marquering, H, Wong, JH, Lopes, D, Reimann, G, Desal, H, Dippel, DWJ, Coutts, S, de Rochemont, RD, Yavagal, D, Ferre, JC, Roos, YBWEM, Liebeskind, DS, Lenthall, R, Molina, C, Al Ajlan, FS, Reddy, V, Dowlatshahi, D, Nader-Antoine, S, Oppenheim, C, Mitha, AP, Davis, SM, Weimar, C, van Oostenbrugge, RJ, Cobo, E, Kleinig, TJ, Donnan, GA, van der Lugt, A, Demchuk, AM, Berkhemer, OA, Boers, AMM, Ford, GA, Muir, KW, Brown, BS, Jovin, T, van Zwam, WH, Mitchell, PJ, Hill, MD, White, P, Bracard, S and Goyal, M
Publicada:
1 oct 2018
Categoría:
Neurology (clinical)
Resumen:
Background Evidence regarding whether imaging can be used effectively to select patients for endovascular thrombectomy (EVT) is scarce. We aimed to investigate the association between baseline imaging features and safety and efficacy of EVT in acute ischaemic stroke caused by anterior large-vessel occlusion.
Methods In this meta-analysis of individual patient-level data, the HERMES collaboration identified in PubMed seven randomised trials in endovascular stroke that compared EVT with standard medical therapy, published between Jan 1, 2010, and Oct 31, 2017. Only trials that required vessel imaging to identify patients with proximal anterior circulation ischaemic stroke and that used predominantly stent retrievers or second-generation neurothrombectomy devices in the EVT group were included. Risk of bias was assessed with the Cochrane handbook methodology. Central investigators, masked to clinical information other than stroke side, categorised baseline imaging features of ischaemic change with the Alberta Stroke Program Early CT Score (ASPECTS) or according to involvement of more than 33% of middle cerebral artery territory, and by thrombus volume, hyperdensity, and collateral status. The primary endpoint was neurological functional disability scored on the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included symptomatic intracranial haemorrhage, parenchymal haematoma type 2 within 5 days of randomisation, and mortality within 90 days. For the primary analysis, we used mixed-methods ordinal logistic regression adjusted for age, sex, National Institutes of Health Stroke Scale score at admission, intravenous alteplase, and time from onset to randomisation, and we used interaction terms to test whether imaging categorisation at baseline modifies the association between treatment and outcome. This meta-analysis was prospectively designed by the HERMES executive committee but has not been registered.
Findings Among 1764 pooled patients, 871 were allocated to the EVT group and 893 to the control group. Risk of bias was low except in the THRACE study, which used unblinded assessment of outcomes 90 days after randomisation and MRI predominantly as the primary baseline imaging tool. The overall treatment effect favoured EVT (adjusted common odds ratio [cOR] for a shift towards better outcome on the mRS 2.00, 95% CI 1.69-2.38; p<0.0001). EVT achieved better outcomes at 90 days than standard medical therapy alone across a broad range of baseline imaging categories. Mortality at 90 days (14.7% vs 17.3%, p=0.15), symptomatic intracranial haemorrhage (3.8% vs 3.5%, p=0.90), and parenchymal haematoma type 2 (5.6% vs 4.8%, p=0.52) did not differ between the EVT and control groups. No treatment effect modification by baseline imaging features was noted for mortality at 90 days and parenchymal haematoma type 2. Among patients with ASPECTS 0-4, symptomatic intracranial haemorrhage was seen in ten (19%) of 52 patients in the EVT group versus three (5%) of 66 patients in the control group (adjusted cOR 3.94, 95% CI 0.94-16.49; P-interaction=0.025), and among patients with more than 33% involvement of middle cerebral artery territory, symptomatic intracranial haemorrhage was observed in 15 (14%) of 108 patients in the EVT group versus four (4%) of 113 patients in the control group (4.17, 1.30-13.44, P-interaction=0.012).
Interpretation EVT achieves better outcomes at 90 days than standard medical therapy across a broad range of baseline imaging categories, including infarcts affecting more than 33% of middle cerebral artery territory or ASPECTS less than 6, although in these patients the risk of symptomatic intracranial haemorrhage was higher in the EVT group than the control group. This analysis provides preliminary evidence for potential use of EVT in patients with large infarcts at baseline. Copyright (c) 2018 Elsevier Ltd. All rights reserved.
Filiaciones:
Roman, LS:
Hosp Clin Barcelona, Dept Intervent Neuroradiol, Imaging Diagnost Ctr, Barcelona, Spain
Menon, BK:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
Blasco, J:
Hosp Clin Barcelona, Dept Intervent Neuroradiol, Imaging Diagnost Ctr, Barcelona, Spain
:
Univ Autonoma Barcelona, Dept Neurosci, Hosp Germans Trias & Pujol, Barcelona, Spain
:
Univ Autonoma Barcelona, Dept Neurosci, Hosp Germans Trias & Pujol, Barcelona, Spain
Majoie, CBLM:
Acad Med Ctr, Dept Radiol & Nucl Med, Amsterdam, Netherlands
Campbell, BCV:
Univ Melbourne, Melbourne Brain Ctr, Dept Med & Neurol, Royal Melbourne Hosp, Melbourne, Vic, Australia
Guillemin, F:
Univ Lorraine, Dept Clin Epidemiol, INSERM, CHRU Nancy,Hop Brabois,CHRU, Nancy, Lorraine, France
Lingsma, H:
Erasmus Univ, Med Ctr, Dept Publ Hlth, Rotterdam, Netherlands
Anxionnat, R:
Univ Lorraine, Dept Diagnost & Intervent Neuroradiol, INSERM, U947, Nancy, Lorraine, France
Epstein, J:
Univ Lorraine, Clin Epidemiol, INSERM, CIC 1433, Nancy, Lorraine, France
Saver, JL:
Univ Calif Los Angeles, David Geffen Sch Med, Dept Neurol, Los Angeles, CA 90095 USA
Marquering, H:
Acad Med Ctr, Dept Biomed Engn & Phys Radiol & Nucl Med, Amsterdam, Netherlands
Wong, JH:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
Lopes, D:
Rush Univ, Med Ctr, Dept Neurosurg & Radiol, Chicago, IL 60612 USA
Reimann, G:
Klinikum Dortmund gGmbH, Stroke Unit, Dortmund, Germany
Klinikum Dortmund gGmbH, Neurol Intens Stn, Dortmund, Germany
Desal, H:
Univ Nantes, Dept Neuroradiol, Nantes, France
Univ Hosp Nantes, Nantes, France
Dippel, DWJ:
Erasmus Univ, Med Ctr, Dept Neurol, Rotterdam, Netherlands
Coutts, S:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
de Rochemont, RD:
Univ Hosp, Dept Radiol, Frankfurt, Germany
Yavagal, D:
Univ Miami, Miller Sch Med, Jackson Mem Hosp, Dept Neurol & Neurosurg, Miami, FL 33136 USA
Ferre, JC:
Univ Rennes 1, Dept Neuroradiol, Rennes, France
Univ Hosp Rennes, Rennes, France
Roos, YBWEM:
Acad Med Ctr, Dept Neurol, Amsterdam, Netherlands
Liebeskind, DS:
Univ Calif Los Angeles, David Geffen Sch Med, Dept Neurol, Los Angeles, CA 90095 USA
Univ Calif Los Angeles, David Geffen Sch Med, Comprehens Stroke Ctr, Los Angeles, CA 90095 USA
Lenthall, R:
Nottingham Univ Hosp NHS Trust, Nottingham, England
Molina, C:
Vall dHebron Hosp, Stroke Unit, Barcelona, Spain
Al Ajlan, FS:
Univ Ottawa, Dept Med Neurol, Ottawa, ON, Canada
Reddy, V:
Drexel Univ, Coll Med, Dept Neurol, Philadelphia, PA 19104 USA
Dowlatshahi, D:
Univ Ottawa, Dept Med Neurol, Ottawa, ON, Canada
Ottawa Hosp Res Inst, Dept Med Neurol, Ottawa, ON, Canada
Nader-Antoine, S:
Hop La Pitie Salpetriere, Paris Hosp Publ Assistance, Dept Neuroradiol, Paris, France
Oppenheim, C:
St Anne Hosp, Dept Neuroradiol, INSERM, U894, Paris, France
Paris Descartes Univ, Paris, France
Mitha, AP:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
Davis, SM:
Univ Melbourne, Melbourne Brain Ctr, Dept Med & Neurol, Royal Melbourne Hosp, Melbourne, Vic, Australia
Weimar, C:
Univ Essen Gesamthsch, Dept Neurol, Essen, Germany
Univ Essen Gesamthsch, Stroke Unit, Essen, Germany
van Oostenbrugge, RJ:
Maastricht Univ, Med Ctr, Dept Neurol, Maastricht, Netherlands
Cobo, E:
Barcelona Tech, Barcelona, Spain
Kleinig, TJ:
Royal Adelaide Hosp, Dept Neurol, Adelaide, SA, Australia
Donnan, GA:
Univ Melbourne, Florey Inst Neurosci & Mental Hlth, Melbourne, Vic, Australia
van der Lugt, A:
Erasmus Univ, Med Ctr, Dept Radiol & Nucl Med, Rotterdam, Netherlands
Demchuk, AM:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
Berkhemer, OA:
Acad Med Ctr, Dept Radiol & Nucl Med, Amsterdam, Netherlands
Erasmus Univ, Med Ctr, Dept Neurol, Rotterdam, Netherlands
Erasmus Univ, Med Ctr, Dept Radiol & Nucl Med, Rotterdam, Netherlands
Maastricht Univ, Med Ctr, Dept Radiol, Maastricht, Netherlands
Boers, AMM:
Acad Med Ctr, Dept Biomed Engn & Phys Radiol & Nucl Med, Amsterdam, Netherlands
Ford, GA:
Oxford Univ Hosp NHS Fdn Trust, Oxford Sci Pk, Oxford, England
Muir, KW:
Univ Glasgow, Queen Elizabeth Univ Hosp, Inst Neurosci & Psychol, Glasgow, Lanark, Scotland
Brown, BS:
Altair Biostat, St Louis Pk, MN USA
Jovin, T:
Univ Pittsburgh, Med Ctr, Dept Neurol, Stroke Inst, Pittsburgh, PA USA
van Zwam, WH:
Maastricht Univ, Med Ctr, Dept Radiol, Maastricht, Netherlands
Cardiovasc Res Inst CARIM, Maastricht, Netherlands
Mitchell, PJ:
Univ Melbourne, Dept Radiol, Royal Melbourne Hosp, Melbourne, Vic, Australia
Hill, MD:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
White, P:
Newcastle Univ, Inst Neurosci, Newcastle Upon Tyne, Tyne & Wear, England
Bracard, S:
Univ Lorraine, Dept Diagnost & Intervent Neuroradiol, INSERM, U947, Nancy, Lorraine, France
Goyal, M:
Univ Calgary, Foothills Hosp, Cumming Sch Med, Dept Clin Neurosci & Radiol, Calgary, AB, Canada
Univ Hosp Nancy, Nancy, Lorraine, France.
Green Accepted, Green Submitted
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