Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials

被引：5800

作者：

Goyal, Mayank ^{[1
,2
]}

Menon, Bijoy K. ^{[1
,2
]}

van Zwam, Wim H. ^{[3
]}

Dippel, Diederik W. J. ^{[4
]}

Mitchell, Peter J. ^{[5
]}

Demchuk, Andrew M. ^{[1
,2
]}

Davalos, Antoni ^{[7
]}

Majoie, Charles B. L. M. ^{[8
]}

van der Lugt, Aad ^{[4
]}

de Miquel, Maria A. ^{[9
]}

Donnan, Geoff Rey A. ^{[10
]}

Roos, Yvo B. W. E. M. ^{[8
]}

Bonafe, Alain ^{[11
]}

Jahan, Reza ^{[12
]}

Diener, Hans-Christoph ^{[13
]}

van den Berg, Lucie A. ^{[8
]}

Levy, Elad I. ^{[14
]}

Berkhemer, Olvert A. ^{[8
]}

Pereira, Vitor M. ^{[15
]}

Rempel, Jeremy ^{[16
]}

Millan, Monica ^{[17
]}

Davis, Stephen M. ^{[6
]}

Roy, Daniel ^{[18
]}

Thornton, John ^{[19
]}

San Roman, Luis ^{[20
]}

Ribo, Marc ^{[21
]}

Beumer, Debbie ^{[3
]}

Stouch, Bruce ^{[22
]}

Brown, Scott ^{[23
]}

Campbell, Bruce C. V. ^{[6
]}

van Oostenbrugge, Robert J. ^{[3
]}

Saver, Jeff Rey L. ^{[24
]}

Hill, Michael D. ^{[1
,2
]}

Jovin, Tudor G. ^{[25
]}

机构：

[1] Univ Calgary, Cummings Sch Med, Dept Clin Neurosci, Hotchkiss Brain Inst, Calgary, AB, Canada

[2] Univ Calgary, Cummings Sch Med, Dept Radiol, Hotchkiss Brain Inst, Calgary, AB, Canada

[3] Maastricht Univ, Med Ctr, Cardiovasc Res Inst Maastricht CARIM, NL-6200 MD Maastricht, Netherlands

[4] Erasmus MC Univ Med Ctr, Rotterdam, Netherlands

[5] Univ Melbourne, Royal Melbourne Hosp, Dept Radiol, Melbourne, Vic 3050, Australia

[6] Univ Melbourne, Royal Melbourne Hosp, Dept Med & Neurol, Melbourne Brain Ctr, Melbourne, Vic 3050, Australia

[7] Hosp Badalona Germans Trias & Pujol, Barcelona, Spain

[8] Univ Amsterdam, Acad Med Ctr, Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

[9] Bellvitge Hosp, Barcelona, Spain

[10] Univ Melbourne, Florey Inst Neurosci & Mental Hlth, Melbourne, Vic, Australia

[11] Hosp Guy de Chaulliac, Montpellier, France

[12] Univ Calif Los Angeles, Med Ctr, Los Angeles, CA 90024 USA

[13] Univ Hosp Essen, Dept Neurol, Essen, Germany

[14] SUNY Buffalo, Buffalo, NY USA

[15] Univ Toronto, Toronto, ON, Canada

[16] Univ Edmonton, Edmonton, AB, Canada

[17] Hosp Badalona Germans Trias & Pujol, Barcelona, Spain

[18] CHUM Notre Dame Hosp, Montreal, PQ, Canada

[19] Beaumont Hosp, Dublin 9, Ireland

[20] Hosp Clin Barcelona, Barcelona, Spain

[21] Hosp Valle De Hebron, Barcelona, Spain

[22] Philadelphia Coll Osteopath Med, Philadelphia, PA USA

[23] Altair Biostat, St Louis Pk, MN USA

[24] Univ Calif Los Angeles, David Geffen Sch Med, Los Angeles, CA 90095 USA

[25] Univ Pittsburgh, Presbyterian Univ Hosp, Med Ctr, Stroke Inst, Pittsburgh, PA 15213 USA

来源：

LANCET | 2016年 / 387卷 / 10029期

关键词：

INTRAVENOUS T-PA; THERAPY; MANAGEMENT; RETRIEVER; TREAT; ONSET;

D O I：

10.1016/S0140-6736(16)00163-X

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

Background In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included. Methods We formed the HERMES collaboration to pool patient-level data from five trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) done between December, 2010, and December, 2014. In these trials, patients with acute ischaemic stroke caused by occlusion of the proximal anterior artery circulation were randomly assigned to receive either endovascular thrombectomy within 12 h of symptom onset or standard care (control), with a primary outcome of reduced disability on the modified Rankin Scale (mRS) at 90 days. By direct access to the study databases, we extracted individual patient data that we used to assess the primary outcome of reduced disability on mRS at 90 days in the pooled population and examine heterogeneity of this treatment effect across prespecified subgroups. To account for between-trial variance we used mixed-effects modelling with random effects for parameters of interest. We then used mixed-effects ordinal logistic regression models to calculate common odds ratios (cOR) for the primary outcome in the whole population (shift analysis) and in subgroups after adjustment for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale score), site of occlusion (internal carotid artery vs M1 segment of middle cerebral artery vs M2 segment of middle cerebral artery), intravenous alteplase (yes vs no), baseline Alberta Stroke Program Early CT score, and time from stroke onset to randomisation. Findings We analysed individual data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control). Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted cOR 2.49, 95% CI 1.76-3.53; p<0.0001). The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2.6. Subgroup analysis of the primary endpoint showed no heterogeneity of treatment effect across prespecified subgroups for reduced disability (p(interaction) = 0.43). Effect sizes favouring endovascular thrombectomy over control were present in several strata of special interest, including in patients aged 80 years or older (cOR 3.68, 95% CI 1.95-6.92), those randomised more than 300 min after symptom onset (1.76, 1.05-2.97), and those not eligible for intravenous alteplase (2.43, 1.30-4.55). Mortality at 90 days and risk of parenchymal haematoma and symptomatic intracranial haemorrhage did not differ between populations. Interpretation Endovascular thrombectomy is of benefit to most patients with acute ischaemic stroke caused by occlusion of the proximal anterior circulation, irrespective of patient characteristics or geographical location. These findings will have global implications on structuring systems of care to provide timely treatment to patients with acute ischaemic stroke due to large vessel occlusion.

引用

页码：1723 / 1731

页数：9

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