Endovascular thrombectomy vs best medical management for late presentation acute ischaemic stroke with large vessel occlusion without CT perfusion or MR imaging selection: A systematic review and meta-analysis

Dhillon, Permesh Singh; Marei, Omar; Podlasek, Anna; Butt, Waleed; Rice, Hal; de Villiers, Laetitia; Carraro do Nascimento, Vinicius; McConachie, Norman; Lenthall, Robert; Nair, Sujit; Malik, Luqman; Bhogal, Pervinder; Dineen, Robert A; England, Timothy J

Abstract

Background: The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from stroke onset for patients with large vessel occlusion (LVO) selected without CT perfusion(CTP) or MR imaging(MRI) is undetermined. We conducted a systematic review and meta-analysis of the current literature comparing outcomes for late presenting patients with LVO treated by best medical management (BMM) with those selected for EVT based only on non-contrast CT(NCCT)/CT angiography(CTA) (without CTP or MRI). Methods: PRISMA guidelines were employed. The primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months. Secondary outcomes were symptomatic intracranial haemorrhage (sICH) and mortality at 3 months. Data were analysed using the random-effects model. Results: Six studies of 2083 patients, including three randomised controlled trials, were included; 1271 patients were treated with EVT and 812 patients with BMM. Compared to BMM, patients treated with EVT demonstrated higher odds of achieving functional independence (39.0 % EVT vs 22.0 % BMM; OR = 2.55, 95 %CI 1.61-4.05,p < 0.0001, I2 = 74 %). The rates of sICH (OR = 2.09, 95 %CI 0.86-5.04,p = 0.10) and mortality (OR = 0.62, 95 %CI 0.35-1.10,p = 0.10) were not significantly different between each cohort. Conclusion: Compared to BMM, late presenting stroke patients selected for EVT eligibility with NCCT/CTA only and treated with EVT achieved significantly higher rates of functional independence at 90 days, without increasing the incidence of sICH or mortality. Whilst these findings indicate that NCCT/CTA only may be used for EVT eligibility selection for patients who present beyond 6 hours from stroke onset, the results should be interpreted with caution due to the substantial heterogeneity between studies.

Citation

Dhillon, P. S., Marei, O., Podlasek, A., Butt, W., Rice, H., de Villiers, L., Carraro do Nascimento, V., McConachie, N., Lenthall, R., Nair, S., Malik, L., Bhogal, P., Dineen, R. A., & England, T. J. (2024). Endovascular thrombectomy vs best medical management for late presentation acute ischaemic stroke with large vessel occlusion without CT perfusion or MR imaging selection: A systematic review and meta-analysis. Journal of Stroke and Cerebrovascular Diseases, 33(11), Article 108002. https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.108002

• Journal Article Type: Article
• Acceptance Date: Sep 6, 2024
• Online Publication Date: Sep 10, 2024
• Publication Date: 2024-11
• Deposit Date: Sep 10, 2024
• Publicly Available Date: Sep 11, 2025
• Journal: Journal of Stroke and Cerebrovascular Diseases
• Print ISSN: 1052-3057
• Electronic ISSN: 1532-8511
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 33
• Issue: 11
• Article Number: 108002
• DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.108002
• Public URL: https://nottingham-repository.worktribe.com/output/39454590
• Publisher URL: https://www.sciencedirect.com/science/article/pii/S1052305724004464
• Additional Information: This article is maintained by: Elsevier; Article Title: Endovascular thrombectomy vs best medical management for late presentation acute ischaemic stroke with large vessel occlusion without CT perfusion or MR imaging selection: A systematic review and meta-analysis; Journal Title: Journal of Stroke and Cerebrovascular Diseases; CrossRef DOI link to publisher maintained version: https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.108002; Content Type: article; Copyright: © 2024 The Authors. Published by Elsevier Inc.