Deans' stroke musings: Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Thursday, April 28, 2022

Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

If all it did was 'improve outcomes', you're discussing failure. WHAT THE FUCK ARE YOU DOING TO PREVENT THAT FAILURE?

Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Shuju Dong^†,

Yanbo Li^†,

Jian Guo,

Yaxi Luo,

Jinghuan Fang,

Li Tang and

Li He^*

Department of Neurology, West China Hospital, Sichuan University, Chengdu, China

Aims: Whether endovascular treatment (EVT) can further improve the prognosis of patients with posterior circulation ischemic stroke (PCIS) is unclear. This meta-analysis aims to compare the efficacy and safety of PCIS patients treated with EVT plus standard medical treatment (SMT) and SMT alone.

Methods: We systematically searched for relevant randomized controlled trials (RCTs) and prospective cohort trials in MEDLINE, EMBASE, and the Cochrane Library up to February 2022. The primary outcome was favorable functional outcome of the modified Rankin Scale (mRS) with scores of 0–2 or 0–3; secondary outcomes included successful recanalization rate, intracranial hemorrhage (ICH), or symptomatic intracranial hemorrhage (sICH) after treatment and 90-day mortality.

Results: We identified six studies including 1, 385 PCIS patients (957 with EVT plus SMT; 428 with SMT alone). EVT plus SMT substantially improved 90-day functional outcomes compared with SMT alone [mRS score of 0–2: RR=1.95, 95% CI (1.52 – 2.51), P < 0.001; mRS score of 0–3: RR = 1.85, 95% CI (1.49 – 2.30), P < 0.001, respectively]. Moreover, compared with SMT, combined treatment significantly improved the rate of successful recanalization [RR = 5.03, 95% CI (3.96–6.40), P < 0.001] and reduced 90-day mortality [RR = 0.71, 95% CI (0.63–0.79), P < 0.001] despite a higher risk of ICH [RR = 6.13, 95% CI (2.50–15.02), P < 0.001] and sICH [RR = 10.47, 95% CI [2.79–39.32), P = 0.001].

Conclusion: Low-to-moderate evidence from RCTs and non-RCTs showed that increased ICH and sICH risk of EVT plus SMT did not translate to a higher risk of unfavorable outcomes compared with SMT and could even promote independence at 90 days in a real-world cohort.

Introduction

Posterior circulation ischemic stroke (PCIS) is caused by blood interruption of the vertebrobasilar arterial system and accounts for approximately 20–25% of all ischemic strokes (1). The most common mechanisms responsible for PCIS are embolism (40%), followed by atherosclerosis (32–35%), and other causes of PCIS include dissection, penetrating small-artery diseases, and other identified or unknown etiologies (2). PCIS represents only 1% of all strokes and 5% of large vessel occlusion (LVO) strokes (3, 4). Despite that, PCIS patients with LVO have an extremely poor prognosis, with a 90-day mortality rate of approximately 35–50%, and the majority of deaths (83%) occur in the hospital (5, 6). PCIS patients have higher mortality than anterior circulation stroke (ACS) patients despite successful revascularization (7, 8).

For PCIS patients, successful recanalization is an independent predictor of a good prognosis (9). Although intravenous thrombolysis (IVT) has been shown to be effective and safe, recanalization rates with IVT remain suboptimal in the setting of LVO (10, 11). Evidence in the ACS suggests that endovascular therapy (EVT) can improve recanalization rates or functional outcomes compared with IVT alone (12–14). And application to patients with PCIS patients appears to similarly improve prognosis in these patients (15–17). However, conclusions regarding the benefit of EVT compared with the conservative treatment in improving the clinical outcome of PCIS patients are still unconfirmed.

Several clinical studies (18–24) and subsequent meta-analyses (25) have shown that the benefits of EVT in patients with PCIS are comparable to those in patients with ACS. Similarly, evidence from several recent studies suggested that patients with PCIS treated with EVT may have higher recanalization rates and better outcomes compared to conservative treatment alone (26, 27). In contrast, other studies have shown that PCIS patients receiving EVT have poorer functional outcomes at 90 days, with a mortality rate of 41.9% (28–30).

Although several meta-analyses have attempted to confirm the additional benefit of EVT on basis of SMT in patients with acute BAO (15, 16, 26), the efficacy and safety of EVT in patients with PCIS remain uncertain due to design and methodological flaws (26, 31). Therefore, we aimed to include the latest research evidence to further evaluate the effectiveness and safety of EVT plus standard medical treatment (SMT) over SMT alone in patients with PCIS and to provide more reliable evidence for clinical decision making in PCIS (6, 24, 32, 33).