Overview of systematic reviews comparing endovascular to best medical treatment for large-vessel occlusion acute ischaemic stroke: an umbrella review

Apostolos Safouris; Lina Palaiodimou; Aristeidis H Katsanos; Odysseas Kargiotis; Konstantinos I Bougioukas; Klearchos Psychogios; Tatiana Sidiropoulou; Stavros Spiliopoulos; Marios-Nikos Psychogios; Georgios Magoufis; Guillaume Turc; Georgios Tsivgoulis

doi:10.1177/17562864241246938

Overview of systematic reviews comparing endovascular to best medical treatment for large-vessel occlusion acute ischaemic stroke: an umbrella review

Ther Adv Neurol Disord. 2024 Apr 29:17:17562864241246938. doi: 10.1177/17562864241246938. eCollection 2024.

Authors

Apostolos Safouris^{1

2}, Lina Palaiodimou², Aristeidis H Katsanos³, Odysseas Kargiotis¹, Konstantinos I Bougioukas⁴, Klearchos Psychogios^{1

2}, Tatiana Sidiropoulou⁵, Stavros Spiliopoulos⁶, Marios-Nikos Psychogios⁷, Georgios Magoufis^{2

8}, Guillaume Turc^{9

10

11

12}, Georgios Tsivgoulis¹³

Affiliations

¹ Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
² Second Department of Neurology, 'Attikon' University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
³ Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
⁴ Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁵ Second Department of Anesthesiology, 'Attikon' University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
⁶ Interventional Radiology Unit, Second Department of Radiology, 'Attikon' University General Hospital, Athens, Greece.
⁷ Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
⁸ Department of Interventional Neuroradiology, Metropolitan Hospital, Piraeus, Greece.
⁹ Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France.
¹⁰ Department of Neurology, Université Paris Cité, Paris, France.
¹¹ Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, Paris, France.
¹² Department of Neurology, FHU NeuroVasc, Paris, France.
¹³ Second Department of Neurology, 'Attikon' University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece.

Abstract

Background: The literature on endovascular treatment (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) has been rapidly increasing after the publication of positive randomized-controlled clinical trials (RCTs) and a plethora of systematic reviews (SRs) showing benefit compared to best medical therapy (BMT) for LVO.

Objectives: An overview of SRs (umbrella review) and meta-analysis of primary RCTs were performed to summarize the literature and present efficacy and safety of EVT.

Design and methods: MEDLINE via Pubmed, Embase and Epistemonikos databases were searched from January 2015 until 15 October 2023. All SRs of RCTs comparing EVT to BMT were included. Quality was assessed using Risk of Bias in Systematic Reviews scores and the RoB 2 Cochrane Collaboration tool, as appropriate. GRADE approach was used to evaluate the strength of evidence. Data were presented according to the Preferred Reporting Items for Overviews of Reviews statement. The primary outcome was 3-month good functional outcome [modified Rankin scale (mRS) score 0-2].

Results: Three eligible SRs and 4 additional RCTs were included in the overview, comprising a total of 24 RCTs, corresponding to 5968 AIS patients with LVO (3044 randomized to EVT versus 2924 patients randomized to BMT). High-quality evidence shows that EVT is associated with an increased likelihood of good functional outcome [risk ratio (RR) 1.78 (95% confidence interval (CI): 1.54-2.06); 166 more per 1000 patients], independent ambulation [mRS-scores 0-3; RR 1.50 (95% CI: 1.37-1.64); 174 more per 1000 patients], excellent functional outcome [mRS-scores 0-1; RR 1.90 (95% CI: 1.62-2.22); 118 more per 1000 patients] at 3 months. EVT was associated with reduced 3-month mortality [RR 0.81 (95% CI: 0.74-0.88); 61 less per 1000 patients] despite an increase in symptomatic intracranial haemorrhage [sICH; RR 1.65 (95% CI: 1.23-2.21); 22 more per 1000 patients].

Conclusion: In patients with AIS due to LVO in the anterior or posterior circulation, within 24 h from symptom onset, EVT improves functional outcomes and increases the chance of survival despite increased sICH risk.

Registration: PROSPERO Registration Number CRD42023461138.

Keywords: NIHSS; endovascular treatment; large-vessel occlusion; meta-analysis; modified Rankin scale; mortality; stroke; symptomatic intracranial haemorrhage; systematic review.

Publication types

Review