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Endovascular therapy versus intravenous thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis

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Abstract

Background

The purpose of our meta-analysis is to evaluate the endovascular therapy (EVT) in patients with cervical artery dissection (CAD)-related acute ischemic stroke (AIS) by comparing its efficacy and safety with the ones of intravenous thrombolysis (IVT).

Methods

A systematic search on EVT to CAD-related ischemic stroke is performed. The meta-analysis models are applied to calculate either the risk ratio (RR) with 95% confidence interval (CI) or pooled proportions with 95% CI of favorable functional outcome (mRS = 0–2), excellent functional outcome (mRS = 0–1), symptomatic intracranial hemorrhage (SICH), mortality and recurrent stroke between EVT and IVT in CAD-related stroke. The differences between the two treatment groups are analyzed by the pooled odds ratio value and Chi-squared test.

Results

A total of 190 patients given EVT and 139 IVT-alone patients are included. By comparing EVT alone and IVT alone, patients treated with EVT alone are more likely to experience favorable outcomes than those treated with IVT alone (71.2% vs 53.4%). Besides, there is no significant difference in excellent functional outcome, SICH, mortality and recurrent stroke between the EVT-alone and IVT-alone groups (all P > 0.05). Towards general EVT (EVT with or without IVT), the outcomes are not significantly different from those of IVT alone except for a higher mortality rate (10.2% vs 3.2%).

Conclusion

Based on our findings, EVT is considered to be more efficacious than IVT for CAD-related AIS patients. Although EVT alone tends to be safe and promising, its safety needs to be further evaluated, particularly for EVT separating from IVT therapy.

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References

  1. Benjamin EJ, Blaha MJ, Chiuve SE, on behalf of the American Heart Association Statistics Committee, and Stroke Statistics Subcommittee et al (2017) Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation 135:e229–e445

    Article  Google Scholar 

  2. Schievink SI (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 345(6):898–906

    Article  Google Scholar 

  3. Vergouwen MD (2012) Intravenous thrombolysis in ischaemic stroke secondary to cervical artery dissection: safe but not effective? Eur J Neurol 19(9):1155–1156

    Article  CAS  Google Scholar 

  4. Wardlaw JM, Murray V, Berge E, del Zoppo GJ (2014) Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 7:CD000213. https://doi.org/10.1002/14651858.CD000213.pub3

    Article  Google Scholar 

  5. Wardlaw JM, Murray V, Berge E et al (2009) Thrombolysis for acute ischaemic stroke. Cochrane Libr 4:CD000213. https://doi.org/10.1002/14651858.CD000213.pub2

    Article  Google Scholar 

  6. Zinkstok SM, Vergouwen MD, Engelter ST et al (2011) Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke 42(9):2515–2520

    Article  Google Scholar 

  7. Rubiera M, Ribo M, Delgado-Mederos R et al (2006) Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke J Cereb Circ 37(9):2301

    Article  Google Scholar 

  8. Lavallée PC, Mazighi M, Saint-Maurice JP et al (2007) Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke 38(8):2270–2274

    Article  Google Scholar 

  9. Lewis JB, Merwick A, Laoide RÓ et al (2013) Therapeutic decision making in acute stroke due to carotid artery dissection: a potential role for percutaneous vascular intervention following intravenous thrombolysis. Case Rep Vasc Med 2013:121696. https://doi.org/10.1155/2013/121696

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Janjua N, Qureshi AI, Kirmani J et al (2006) Stent-supported angioplasty for acute stroke caused by carotid dissection. Neurocrit Care 4(1):47–53

    Article  Google Scholar 

  11. Baumgartner RW, Georgiadis D, Nedeltchev K et al (2008) Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke 39:e27–e28

    Article  Google Scholar 

  12. Engelter ST, Dallongeville J, Kloss M et al (2012) Thrombolysis in cervical artery dissection–data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database. Eur J Neurol 19(9):1199–1206

    Article  CAS  Google Scholar 

  13. Vergouwen MD, Beentjes PA, Nederkoorn PJ (2009) Thrombolysis in patients with acute ischemic stroke due to arterial extracranial dissection. Eur J Neurol 16:646–649

    Article  CAS  Google Scholar 

  14. Jensen J, Salottolo K, Frei D et al (2017) Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection. J Neurointerventional Surg 9(7):654–658. https://doi.org/10.1136/neurintsurg-2016-012421

    Article  Google Scholar 

  15. Marnat G, Bühlmann M, Eker OF et al (2018) Multicentric experience in distal-to-proximal revascularization of tandem occlusion stroke related to internal carotid artery dissection. Am J Neuroradiol 39(6):1093–1099

    Article  CAS  Google Scholar 

  16. Fields JD, Lutsep HL, Rymer MR et al (2012) Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci 18(1):74

    CAS  Google Scholar 

  17. Traenka C, Jung S, Gralla J et al (2018) Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke—results from the SWISS registry. Eur Stroke J 3(1):47–56. https://doi.org/10.1177/2396987317748545

    Article  PubMed  PubMed Central  Google Scholar 

  18. Murias Quintana E, Vega Valdés P, Morales Deza E et al (2016) Endovascular reconstruction of internal carotid artery dissection in patients with acute ischemic stroke using the Wingspan stent. Interv Neuroradiology J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci 22(6):700–704

    Google Scholar 

  19. Haussen DC, Jadhav A, Jovin T et al (2015) Endovascular management vs intravenous thrombolysis for acute stroke secondary to carotid artery dissection: local experience and systematic review. Neurosurgery 78(5):709

    Article  Google Scholar 

  20. Lekoubou A, Cho TH, Nighoghossian N et al (2010) Combined intravenous recombinant-tissular plasminogen activator and endovascular treatment of spontaneous occlusive internal carotid dissection with tandem intracranial artery occlusion. Eur Neurol 63(4):211–214

    Article  CAS  Google Scholar 

  21. Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11

    Article  Google Scholar 

  22. Goyal M, Demchuk AM, Menon BK et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030

    Article  CAS  Google Scholar 

  23. Jovin TG, Chamorro A, Cobo E et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372(24):2296–2306

    Article  CAS  Google Scholar 

  24. Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372(24):2285–2295

    Article  CAS  Google Scholar 

  25. Crespo Araico LA, Vera Lechuga R, Cruz-Culebras A et al (2019) Reperfusion therapy in patients with acute ischaemic stroke caused by cervical artery dissection. Neurologia 34(3):153–158. https://doi.org/10.1016/j.nrl.2016.11.005

    Article  CAS  PubMed  Google Scholar 

  26. WHO Special Report (1989) Stroke—1989. Recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO Task Force on stroke and other cerebrovascular disorders. Stroke 20(10):1407–1431

    Article  Google Scholar 

  27. Vandenbroucke JP, von Elm E, Altman DG et al (2014) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Int J Surg 12(12):1500–1524. https://doi.org/10.1016/j.ijsu.2014.07.014

    Article  PubMed  Google Scholar 

  28. Elm EV, Altman DG, Egger M et al (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting of observational studies. Der Internist 49(6):688–693

    Article  Google Scholar 

  29. Higgins JPT, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558

    Article  Google Scholar 

  30. Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560

    Article  Google Scholar 

  31. Dziewas R, Konrad C, Dräger B et al (2003) Cervical artery dissection-clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 250(10):1179–1184

    Article  Google Scholar 

  32. Arnold M, Nedeltchev K, Sturzenegger M et al (2002) Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature. Arch Neurol 59(4):549–553

    Article  Google Scholar 

  33. Broderick JP, Adeoye O, Elm J (2017) Evolution of the Modified Rankin Scale and its use in future stroke trials. Stroke 48(7):2007–2012. https://doi.org/10.1161/STROKEAHA.117.017866

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lin J, Sun Y, Zhao S, Xu J, Zhao C (2016) Safety and efficacy of thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis of observational studies. Cerebrovasc Dis 42(3–4):272–279. https://doi.org/10.1159/000446004

    Article  PubMed  Google Scholar 

  35. Schievink WI, Wijdicks EF, Kuiper JD (1998) Seasonal pattern of spontaneous cervical artery dissection. J Neurosurg 89(1):101–103

    Article  CAS  Google Scholar 

  36. Benninger DH, Georgiadis D, Kremer C et al (2004) Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke 35(2):482–485

    Article  CAS  Google Scholar 

  37. Engelter ST, Brandt T, Debette S et al (2007) Antiplatelets versus anticoagulation in cervical artery dissection. Stroke 38(9):2605–2611

    Article  Google Scholar 

  38. Kim YS, Garami Z, Mikulik R et al (2005) Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 36(4):869–871

    Article  Google Scholar 

  39. Lyrer P, Engelter S (2010) Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev 10:CD000255. https://doi.org/10.1002/14651858.CD000255.pub2

    Article  Google Scholar 

  40. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587

    Article  Google Scholar 

  41. Wahlgren N, Ahmed N, Dávalos A et al (2007) Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 369(9558):275–282

    Article  CAS  Google Scholar 

  42. Trouillas P, von Kummer R (2006) Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke. Stroke 37:556–561

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Emergency Department, Zhongshan Hospital Xiamen University, No. 201, South Hubin Street, Siming District, Xiamen, 361000, Fujian, People’s Republic of China

    Jueying Lin

  2. Department of Statistics, University of South Carolina, Columbia, SC, USA

    Yawei Liang & Juexin Lin

Authors
  1. Jueying Lin
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  2. Yawei Liang
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  3. Juexin Lin
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Corresponding author

Correspondence to Jueying Lin.

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Electronic supplementary material

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415_2019_9474_MOESM1_ESM.docx

Figure B Forest plot presenting the estimation and 95% confidence interval of risk ratio for the subgroup analyses of NIHSS score in relation to favorable functional outcome between general-EVT group and IVT-alone group (DOCX 139 kb)

415_2019_9474_MOESM2_ESM.docx

Figure C Forest plot presenting the estimation and 95% confidence interval of odds ratio for the subgroup analyses of SICH in relation to favorable functional outcome between general-EVT group and IVT-alone group (DOCX 137 kb)

Appendices

Appendix A: The authors

Name

Location

Role

Contribution

Jueying Lin

Zhongshan Hospital Xiamen University, Xiamen

Author

Design study; searched literatures; extraction of data; analyzed the data; drafted the manuscript for intellectual content

Yawei Liang

University of South Carolina, Columbia

Author

Searched literatures; extraction of data; analyzed the data; drafting and revision of manuscript

Juexin Lin

University of South Carolina, Columbia

Author

Analyzed the data by statistics; drafting and revision of manuscript

Appendix B: Subgroup meta-analysis of NIHSS

The analysis is conducted with a threshold at 20 (no NIHSS, NIHSS 9–19, and NIHSS ≥ 20). As shown in the data, patients with less severe stroke tend to receive more benefits from ET than simple IVT. Nevertheless, we do not have enough evidence to conclude a statistically significant difference between two treatment groups (RR 0.67, 95% CI 0.35–1.30, P = 0.24, for no NIHSS strata; RR 1.02, 95% CI 0.72–1.46, P = 0.89, for NIHSS 9–19 strata; RR 2.09, 95% CI 0.57–2.06, P = 0.80, for NIHSS ≥ 20 strata; ESM Figure B) or among the NIHSS subgroups (heterogeneity test of subgroups: I2 = 0%, P > 0.05, ESM Figure B).

Appendix C: Subgroup meta-analysis of SICH criteria

Most selected studies fall in three of widely used SICH criteria: NINDS criteria [40], SITS criteria [41], European Cooperative Acute Stroke Study (ECASS II) criteria [42]. For those studies without clear definition on SICH, we contact the authors for clarification and classify the SICH criteria according to their response. But for those without responses, we mark them as a separate group “no clear definition”. Then a subgroup meta-analysis of SICH is conducted across all SICH standards (NINDS, SITS, ECASS II, no clear definition), which results in non-heterogeneity of its different standards (I2 = 11.3%, P > 0.05, ESM Figure C).

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Lin, J., Liang, Y. & Lin, J. Endovascular therapy versus intravenous thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis. J Neurol 267, 1585–1593 (2020). https://doi.org/10.1007/s00415-019-09474-y

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