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

Journal of Neurology volume 267, pages 1585–1593 (2020)Cite this article

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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Author information

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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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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  • DOI: https://doi.org/10.1007/s00415-019-09474-y

Keywords

  • Cervical artery dissection
  • Ischemic stroke
  • Endovascular therapy
  • Intravenous thrombolysis
  • Meta-analysis