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Mechanical Endovascular Therapy in Ischaemic Stroke: Temporal Trend of Outcomes

Two recent systematic reviews (1,2) have assessed the effectiveness of mechanical endovascular therapy (MET) to manage the acute phase of stroke, but new data have been published thereafter. In this context, our aim was to update these meta-analytic results and to investigate how effectiveness has changed over years. Our study was restricted to observational (single-arm) studies which were thought to better represent a real-world setting. We searched all such studies evaluating MET and employing the end-point of any revascularization, complete revascularization, functional outcome, and mortality. As compared with the previous reviews (1,2), 20 more studies were found, but unlike Baker et al. (2), case reports of 10 patients were excluded. Overall, we identified 58 studies published from 1994 to 2012 that evaluated 3066 patients (Appendix S1). Our analysis of these 58 studies (proportion meta-analysis based on randomeffect model (3,4)) yielded the following pooled proportions with 95% confidence interval (95% CI): any revascularization, 80·7% (95% CI: 75·5% to 85·3%); complete revascularization, 50·6 (95% CI: 37·8 to 63·3); functional outcome, 39·2 (95% CI: 32·8 to 45·8); mortality, 24·5% (95% CI: 19·5% to 29·8%). Our results (see Appendix S1 for study-specific rates of individual endpoints) are in keeping with those previously published (2,3). Figure 1 shows the results of our metaregression (based on standard regression techniques (5)) that separately examined the four end-points. In these analyses, MET was associated with an improvement in total revascularization rate and a decrease in mortality over time. While the time dependency of these indexes is likely to reflect improvements in devices, techniques, and expertise, the shortcomings of our analysis must however be kept in mind (e.g. the single-arm nature, and lack of randomization and blinding in these studies). In conclusion, our results suggest that, in a real-world setting, MET shows a progressively better effectiveness with time, but the heterogeneity of its outcomes is still wide.