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MA: Limited data shows thrombectomy 6 to 24 hours after stroke onset is effective in highly selected persons
Clinical Question
Is delayed thrombectomy (6 to 24 hours after stroke onset) safe and effective?
Bottom line
Although the existing data are limited to a few small trials, it appears that patients who undergo delayed endovascular therapy after stroke are more likely to have favorable 90-day functional outcomes than patients who do not undergo thrombectomy. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Industry
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
These researchers, funded by a device manufacturer, searched several databases to identify randomized trials of endovascular thrombectomy that enrolled participants beyond the standard 6 hours after having last been seen well (a conservative proxy for stroke onset). The authors identified 6 trials with 505 persons (266 intervention group and 239 control group) who were deemed to have salvageable brain tissue based on a substantial mismatch between the extent of infarcted brain and the extent of at-risk brain tissue based on computed tomography perfusion studies or magnetic resonance imaging. The authors do not report on the methodologic quality of the included studies and do not report if the allocation in the included studies was concealed. They obtained the original patient-level data and used intention to treat to analyze 90-day functional status (disability on the modified Rankin Scale [mRS]) and complications (mortality and symptomatic intracerebral hemorrhage [ICH]). The mRS ranges from 0 to 6. An mRS score of 0 indicates a person with no symptoms, a score of 1 indicates a person with no disability despite symptoms, and a score of 2 indicates a person with slight disability but still independent; higher scores are worse. More patients who received delayed therapy experienced more desirable functional outcomes than did control patients (see table). Although more control patients died and more intervention patients had ICH, the differences were not statistically significant, possibly representing the small total number of these events. Despite the small number of patients, the authors performed multiple subgroup analyses and concluded the data consistently favored the intervention group.
| Outcome | Intervention | Control | Number Needed to Treat (95% CI) |
| mRS 0–1 | 75/266 (28.2%) | 30/238 (12.6%) | 7 (5 - 12) |
| mRS 0–2 | 122/266 (45.9%) | 46/238 (19.3%) | 4 (3 - 6) |
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Concerns re: this study
Industry funded study, poor methodology, opaque criteria for inclusion, tons of potential bias. Really seems to be fishing for a positive outcome...