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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

Characteristic	Control	Active
Sample size	3171 patients	2019 patients
Mean age	67.9 years	67.1 years
Male	56%	55%
Mean NIHSS	3.2	3.7
IVT pretreatment	81%	51%

Arms

Field	Endovascular Treatment	Control
Intervention	Mechanical thrombectomy or thromboaspiration plus best medical treatment	Best medical treatment alone (including intravenous thrombolysis when appropriate)
Duration	Acute intervention with 3-month follow-up	Standard care with 3-month follow-up

Outcomes

Outcome	Type	Control	Intervention	HR / OR / RR	P-value
Excellent functional outcome at 3 months (modified Rankin Scale score 0-1)	Primary	Variable across studies	Variable across studies		Not significant
Good functional outcome at 3 months (mRS 0-2)	Secondary	Variable across studies	Variable across studies	1.01	Not significant
Reduced disability (shift analysis across all mRS scores)	Secondary	Variable across studies	Variable across studies	0.92	Not significant
All-cause mortality at 3 months	Secondary	Variable across studies	Variable across studies	1.34	Not significant
Symptomatic intracranial hemorrhage	Adverse	Lower rates	Higher rates	3.53	<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)