Endovascular therapy for acute ischaemic stroke: a systematic review and meta-analysis of randomized trials

Eur Heart J. 2015 Sep 14;36(35):2373-80. doi: 10.1093/eurheartj/ehv270. Epub 2015 Jun 12.


Aims: Evidence from randomized controlled trials (RCTs) evaluating possible benefits of endovascular therapy (EVT) for acute ischaemic stroke has shown conflicting results. The purpose of this meta-analysis was to systematically examine clinical outcomes in RCTs comparing the use of intravenous (IV) fibrinolysis alone to IV fibrinolysis plus EVT, for the treatment of acute ischaemic stroke.

Methods and results: We selected English language RCTs, comparing EVT plus IV tissue-type plasminogen activator (tPA) (if eligible) with IV tPA alone in eligible patients for the treatment of acute ischaemic stroke. The primary endpoint was good functional outcome [modified Rankin Scale (mRS) of 0-2]. Other major endpoints of interest were all-cause mortality and symptomatic intracerebral haemorrhage (sICH). The meta-analysis included 8 RCTs that randomized 2423 patients with large-vessel, anterior-circulation stroke. EVT significantly improved the rate of functional independence (90-day mRS of 0-2) when compared with IV fibrinolysis [odds ratio (OR) 1.73, 95% confidence interval (CI) 1.18-2.53, number needed to treat (NNT) = 9.3]. The all-cause mortality was lower with EVT compared with the control group; however, the result did not reach statistical significance (OR 0.89, 95% CI 0.68-1.15). The rate of sICH was not higher with EVT (OR 1.07, 95% CI 0.73-1.56). Analyses from only the recent trials (reported in 2014-15) showed further benefit (OR of mRS 0-2: 2.42, 95% CI 1.91-3.08, NNT = 5) with similar safety results.

Conclusion: In centres with advanced systems of stroke care, EVT significantly improved functional outcomes (without compromising safety) in patients with acute ischaemic stroke due to anterior circulation, large artery occlusion, compared with standard therapy.

Keywords: Endovascular; Meta-analysis; Outcomes; Stroke; Thrombolytics.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Endovascular Procedures / methods*
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Infusions, Intravenous
  • Randomized Controlled Trials as Topic
  • Stroke / therapy*
  • Thrombolytic Therapy / methods
  • Tissue Plasminogen Activator / therapeutic use
  • Treatment Outcome


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator