Meta-analysis of randomized intra-arterial thrombolytic trials for the treatment of acute stroke due to middle cerebral artery occlusion

Jeremy D. Fields, Pooja Khatri, Gary Nesbit, Kenneth C. Liu, Stanley L. Barnwell, Helmi Lutsep, Wayne Clark, Maarten G. Lansberg

Research output: Contribution to journalArticle

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Abstract

Background: Randomized clinical trials supporting the use of intra-arterial administration of thrombolytics (IAT) for the treatment of stroke due to middle cerebral artery (MCA) occlusion have been positive on some, but not all, endpoints. A meta-analysis was performed to estimate with more precision the effect of IAT on several key clinical endpoints. Methods: All randomized trials of IAT in the treatment of MCA stroke were identified by PUBMED search and by hand search of potentially relevant references. Trial methodologies were assessed for compatibility in study protocols and statistical analysis. A meta-analysis was performed evaluating the effect of IAT on functional outcome at 90 days and symptomatic intracranial hemorrhage (SICH) within 24 h. Results: Three trials met the criteria for the metaanalysis. IAT treated patients were significantly more likely to have a modified Rankin scale (mRS) ≤1 (31% vs 20%, OR 2.0, 95% CI 1.2 to 3.4, p=0.01); mRS ≤2 (43% vs 31%, OR 1.9, 95% CI 1.2 to 3.0, p=0.01); and NIH Stroke Scale score 0 or 1 (23% vs 12%, OR 2.4, 95% CI 1.3 to 4.4, p=0.007) at the 90 day follow-up. There was no effect on mortality at 90 days (20% vs 19%, OR 0.84, 95% CI 0.5 to 1.5). The risk of SICH was significantly increased in the active treatment arms (11% vs 2%, OR 4.6, 95% CI 1.3 to 16, p=0.02). Conclusions: Our meta-analysis demonstrates that all standard functional endpoints for stroke trials were substantially improved in the active treatment arms. Despite an increased risk of SICH, there was no effect on mortality. These results support endovascular treatment of acute ischemic stroke due to MCA occlusion with intra-arterial thrombolytics.

Original languageEnglish (US)
Pages (from-to)151-155
Number of pages5
JournalJournal of NeuroInterventional Surgery
Volume3
Issue number2
DOIs
StatePublished - Jun 2011

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Middle Cerebral Artery Infarction
Meta-Analysis
Stroke
Intracranial Hemorrhages
Therapeutics
Mortality
Randomized Controlled Trials

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

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Meta-analysis of randomized intra-arterial thrombolytic trials for the treatment of acute stroke due to middle cerebral artery occlusion. / Fields, Jeremy D.; Khatri, Pooja; Nesbit, Gary; Liu, Kenneth C.; Barnwell, Stanley L.; Lutsep, Helmi; Clark, Wayne; Lansberg, Maarten G.

In: Journal of NeuroInterventional Surgery, Vol. 3, No. 2, 06.2011, p. 151-155.

Research output: Contribution to journalArticle

Fields, Jeremy D. ; Khatri, Pooja ; Nesbit, Gary ; Liu, Kenneth C. ; Barnwell, Stanley L. ; Lutsep, Helmi ; Clark, Wayne ; Lansberg, Maarten G. / Meta-analysis of randomized intra-arterial thrombolytic trials for the treatment of acute stroke due to middle cerebral artery occlusion. In: Journal of NeuroInterventional Surgery. 2011 ; Vol. 3, No. 2. pp. 151-155.
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abstract = "Background: Randomized clinical trials supporting the use of intra-arterial administration of thrombolytics (IAT) for the treatment of stroke due to middle cerebral artery (MCA) occlusion have been positive on some, but not all, endpoints. A meta-analysis was performed to estimate with more precision the effect of IAT on several key clinical endpoints. Methods: All randomized trials of IAT in the treatment of MCA stroke were identified by PUBMED search and by hand search of potentially relevant references. Trial methodologies were assessed for compatibility in study protocols and statistical analysis. A meta-analysis was performed evaluating the effect of IAT on functional outcome at 90 days and symptomatic intracranial hemorrhage (SICH) within 24 h. Results: Three trials met the criteria for the metaanalysis. IAT treated patients were significantly more likely to have a modified Rankin scale (mRS) ≤1 (31{\%} vs 20{\%}, OR 2.0, 95{\%} CI 1.2 to 3.4, p=0.01); mRS ≤2 (43{\%} vs 31{\%}, OR 1.9, 95{\%} CI 1.2 to 3.0, p=0.01); and NIH Stroke Scale score 0 or 1 (23{\%} vs 12{\%}, OR 2.4, 95{\%} CI 1.3 to 4.4, p=0.007) at the 90 day follow-up. There was no effect on mortality at 90 days (20{\%} vs 19{\%}, OR 0.84, 95{\%} CI 0.5 to 1.5). The risk of SICH was significantly increased in the active treatment arms (11{\%} vs 2{\%}, OR 4.6, 95{\%} CI 1.3 to 16, p=0.02). Conclusions: Our meta-analysis demonstrates that all standard functional endpoints for stroke trials were substantially improved in the active treatment arms. Despite an increased risk of SICH, there was no effect on mortality. These results support endovascular treatment of acute ischemic stroke due to MCA occlusion with intra-arterial thrombolytics.",
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AU - Fields, Jeremy D.

AU - Khatri, Pooja

AU - Nesbit, Gary

AU - Liu, Kenneth C.

AU - Barnwell, Stanley L.

AU - Lutsep, Helmi

AU - Clark, Wayne

AU - Lansberg, Maarten G.

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AB - Background: Randomized clinical trials supporting the use of intra-arterial administration of thrombolytics (IAT) for the treatment of stroke due to middle cerebral artery (MCA) occlusion have been positive on some, but not all, endpoints. A meta-analysis was performed to estimate with more precision the effect of IAT on several key clinical endpoints. Methods: All randomized trials of IAT in the treatment of MCA stroke were identified by PUBMED search and by hand search of potentially relevant references. Trial methodologies were assessed for compatibility in study protocols and statistical analysis. A meta-analysis was performed evaluating the effect of IAT on functional outcome at 90 days and symptomatic intracranial hemorrhage (SICH) within 24 h. Results: Three trials met the criteria for the metaanalysis. IAT treated patients were significantly more likely to have a modified Rankin scale (mRS) ≤1 (31% vs 20%, OR 2.0, 95% CI 1.2 to 3.4, p=0.01); mRS ≤2 (43% vs 31%, OR 1.9, 95% CI 1.2 to 3.0, p=0.01); and NIH Stroke Scale score 0 or 1 (23% vs 12%, OR 2.4, 95% CI 1.3 to 4.4, p=0.007) at the 90 day follow-up. There was no effect on mortality at 90 days (20% vs 19%, OR 0.84, 95% CI 0.5 to 1.5). The risk of SICH was significantly increased in the active treatment arms (11% vs 2%, OR 4.6, 95% CI 1.3 to 16, p=0.02). Conclusions: Our meta-analysis demonstrates that all standard functional endpoints for stroke trials were substantially improved in the active treatment arms. Despite an increased risk of SICH, there was no effect on mortality. These results support endovascular treatment of acute ischemic stroke due to MCA occlusion with intra-arterial thrombolytics.

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