Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

Omar Marei; Anna Podlasek; Emma Soo; Waleed Butt; Benjamin Gory; Thanh N Nguyen; Jason P Appleton; Sébastien Richard; Hal Rice; Laetitia de Villiers; Vinicius Carraro do Nascimento; Luis Domitrovic; Norman McConachie; Robert Lenthall; Sujit Nair; Luqman Malik; Jasmin Panesar; Kailash Krishnan; Pervinder Bhogal; Robert A Dineen; Timothy J England; Bruce C V Campbell; Permesh Singh Dhillon

doi:10.1136/jnis-2023-021244

Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

J Neurointerv Surg. 2024 Jan 19:jnis-2023-021244. doi: 10.1136/jnis-2023-021244. Online ahead of print.

Authors

Omar Marei¹, Anna Podlasek², Emma Soo¹, Waleed Butt³, Benjamin Gory⁴, Thanh N Nguyen^{5

6}, Jason P Appleton^{7

8}, Sébastien Richard⁹, Hal Rice¹⁰, Laetitia de Villiers¹⁰, Vinicius Carraro do Nascimento¹⁰, Luis Domitrovic¹⁰, Norman McConachie¹¹, Robert Lenthall¹¹, Sujit Nair¹¹, Luqman Malik¹¹, Jasmin Panesar¹¹, Kailash Krishnan^{7

12}, Pervinder Bhogal¹³, Robert A Dineen^{1

14}, Timothy J England^{12

15}, Bruce C V Campbell^{16

17}, Permesh Singh Dhillon^{18

10}

Affiliations

¹ Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.
² Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK.
³ Queen Elizabeth Hospital Birmingham, Birmingham, UK.
⁴ Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France.
⁵ Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.
⁶ Radiology, Boston Medical Center Department of Radiology, Boston, Massachusetts, USA.
⁷ Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.
⁸ Stroke Trials Unit, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK.
⁹ Department of Neurology, Université de Lorraine, Nancy, France.
¹⁰ Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia.
¹¹ Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.
¹² Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.
¹³ Interventional Neuroradiology, Royal London Hospital, London, UK.
¹⁴ NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.
¹⁵ Stroke Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.
¹⁶ Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia.
¹⁷ Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia.
¹⁸ Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK permesh.dhillon@nottingham.ac.uk.

PMID: 38253378
DOI: 10.1136/jnis-2023-021244

Abstract

Background: Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis.

Methods: Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

Results: 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I²=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I²=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I²=76%) were not significantly different.

Conclusion: The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.

Keywords: Embolic; Hemorrhage; Stroke; Thrombectomy; Thrombolysis.