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EVT vs BMT Low NIHSS Metanalysis

Medical Management Versus Endovascular Treatment for Large-Vessel Occlusion Anterior Circulation Stroke With Low NIHSS

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Year of Publication: 2023

Authors: Apostolos Safouris, Lina Palaiodimou, Sándor Nardai, ..., Georgios Tsivgoulis

Journal: Stroke

Citation: Stroke. 2023;54:2265–2275

Link: https://www.ahajournals.org/doi/10.1161/STROKEAHA.123.043937

PDF: https://www.ahajournals.org/doi/epub/10....EAHA.123.043937

Clinical Question

Is endovascular treatment on top of best medical treatment beneficial compared with best medical treatment alone for anterior circulation large-vessel occlusion stroke patients presenting with low NIHSS scores (≤5)?

Bottom Line

Endovascular treatment appears equivalent to best medical treatment for patients with anterior circulation large-vessel occlusion and low baseline NIHSS, despite an increased risk for symptomatic intracranial hemorrhage, indicating that randomized controlled trials are needed for definitive evidence.

Major Points

  • Systematic review and meta-analysis of 11 observational studies comprising 2019 EVT patients versus 3171 BMT patients
  • EVT was not associated with excellent functional outcome at 3 months (mRS 0-1; RR 1.10, 95% CI 0.93-1.31)
  • No significant differences in good functional outcome (mRS 0-2; RR 1.01, 95% CI 0.89-1.16) or mortality
  • Symptomatic intracranial hemorrhage was significantly more common with EVT (RR 3.53, 95% CI 2.35-5.31)
  • Results consistent across intention-to-treat and per-protocol study designs and in propensity score matched analyses

Design

Study Type: Systematic review and meta-analysis of observational cohort studies

Randomization:

Blinding: Not applicable

Enrollment Period: Studies published until December 28, 2022

Follow-up Duration: 3 months

Countries: Multinational

Sample Size: 5190

Analysis: Random-effects meta-analysis using R software version 3.5.0; risk ratios with 95% CI; subgroup analysis by study design (intention-to-treat vs per-protocol); sensitivity analysis with propensity score matched studies

Inclusion Criteria

  • Clinical trials or observational cohort studies
  • Adult patients with acute ischemic stroke due to anterior circulation large-vessel occlusion
  • Admission NIHSS score ≤5
  • Comparison of EVT (mechanical thrombectomy or thromboaspiration) plus BMT versus BMT alone
  • Functional outcome reporting at 3 months using modified Rankin Scale

Exclusion Criteria

  • Studies without functional outcome data at 3 months
  • Non-anterior circulation strokes
  • NIHSS >5
  • Single-arm studies without comparison groups
  • Narrative reviews or case reports

Baseline Characteristics

CharacteristicControlActive
Sample size3171 patients2019 patients
Mean age67.9 years67.1 years
Male56%55%
Mean NIHSS3.23.7
IVT pretreatment81%51%

Arms

FieldEndovascular TreatmentControl
InterventionMechanical thrombectomy or thromboaspiration plus best medical treatmentBest medical treatment alone (including intravenous thrombolysis when appropriate)
DurationAcute intervention with 3-month follow-upStandard care with 3-month follow-up

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Excellent functional outcome at 3 months (modified Rankin Scale score 0-1)PrimaryVariable across studiesVariable across studiesNot significant
Good functional outcome at 3 months (mRS 0-2)SecondaryVariable across studiesVariable across studies1.01Not significant
Reduced disability (shift analysis across all mRS scores)SecondaryVariable across studiesVariable across studies0.92Not significant
All-cause mortality at 3 monthsSecondaryVariable across studiesVariable across studies1.34Not significant
Symptomatic intracranial hemorrhageAdverseLower ratesHigher rates3.53<0.05

Subgroup Analysis

No significant subgroup differences between intention-to-treat and per-protocol studies for primary and secondary outcomes except for reduced disability analysis

Criticisms

  • Study-based meta-analysis lacking individual patient data
  • Only observational studies included with imbalances between treatment arms
  • Substantial risk of bias in all included studies related to unmeasured selection bias
  • Significant heterogeneity present in most outcomes
  • Unavailable data on oral anticoagulation pretreatment across studies
  • Could not perform targeted analysis stratified by occlusion site due to lack of individual patient data
  • Meta-regression for baseline NIHSS could not be performed (data available for <10 studies)
  • All studies had serious overall risk of bias per ROBINS-I assessment

Funding

None reported

Based on: EVT vs BMT Low NIHSS Metanalysis (Stroke, 2023)

Authors: Apostolos Safouris, Lina Palaiodimou, Sándor Nardai, ..., Georgios Tsivgoulis

Citation: Stroke. 2023;54:2265–2275

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