Abstract
Mechanical thrombectomy with stent retrievers is an effective treatment for patients with ischemic stroke. Results of recent meta-analyses report that the treatment is safe. However, the endpoints recurrent stroke, vasospasms, and subarachnoid hemorrhage have not been evaluated sufficiently. Hence, we extracted data on these outcomes from the five recent thrombectomy trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA published in 2015). Subsequently, we conducted meta-analyses for each outcome. We report the results of the fixed, as well as the random effects model. Three studies reported data on recurrent strokes. While the results did not reach statistical significance in the random effects model (despite a three times elevated risk), the fixed effects model revealed a significantly higher rate of recurrent strokes after thrombectomy. Four studies reported data on subarachnoid hemorrhage. The higher pooled rates in the intervention groups were statistically significant in both, the fixed and the random effects model. One study reported on vasospasms. We recorded 14 events in the intervention group and none in the control group. The efficacy of mechanical thrombectomy is not questioned, yet our results indicate an increased risk for recurrent strokes, subarachnoid hemorrhage, and vasospasms post-treatment. Therefore, we strongly recommend a thoroughly surveillance, concerning these adverse events in future clinical trials and routine registries.
Similar content being viewed by others
References
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, de du Mesnil Rochemont R, Singer OC, Jahan R (2015) Stent-retriever thrombectomy after intravenous t-PA vs t-PA alone in stroke. N Engl J Med 372(24):2285–2295. doi:10.1056/NEJMoa1415061
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, Millan M, Urra X, Cardona P, Lopez-Cancio E, Tomasello A, Castano C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Perez M, Goyal M, Demchuk AM, von Kummer R, Gallofre M, Davalos A (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372(24):2296–2306. doi:10.1056/NEJMoa1503780
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372(11):1009–1018. doi:10.1056/NEJMoa1414792
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030. doi:10.1056/NEJMoa1414905
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama a Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20. doi:10.1056/NEJMoa1411587
EUnetHTA2015 (2015) Endovascular therapy using mechanical thrombectomy devices for acute ischaemic stroke. EUnetHTA, Ireland
Yarbrough CK, Ong CJ, Beyer AB, Lipsey K, Derdeyn CP (2015) Endovascular thrombectomy for anterior circulation stroke: systematic review and meta-analysis. Stroke J Cereb Circ 46(11):3177–3183. doi:10.1161/STROKEAHA.115.009847
Campbell BCV, Hill MD, Rubiera M, Menon BK, Demchuk A, Donnan GA, Roy D, Thornton J, Dorado L, Bonafe A, Levy EI, Diener H-C, Hernández-Pérez M, Pereira VM, Blasco J, Quesada H, Rempel J, Jahan R, Davis SM, Stouch BC, Mitchell PJ, Jovin TG, Saver JL, Goyal M (2016) Safety and efficacy of solitaire stent thrombectomy: individual patient data meta-analysis of randomized trials. Stroke J Cereb Circ 47(3):798–806. doi:10.1161/strokeaha.115.012360
Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Davalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millan M, Davis SM, Roy D, Thornton J, Roman LS, Ribo M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387(10029):1723–1731. doi:10.1016/S0140-6736(16)00163-X
Armin SS, Colohan ART, Zhang JH (2008) Vasospasm in traumatic brain injury. Acta Neurochir Suppl 104(13):421–425. doi:10.1007/978-3-211-75718-5
Ferro JM, Canhao P, Peralta R (2008) Update on subarachnoid haemorrhage. J Neurol 255(4):465–479. doi:10.1007/s00415-008-0606-3
Kramer DR, Winer JL, Pease BAM, Amar AP, Mack WJ (2013) Cerebral vasospasm in traumatic brain injury. Neurol Res Int 2013:7. doi:10.1155/2013/415813
Wilson CW, Grande MC, Hoyt BD (eds) (2007) Trauma: critical care. CRC Press, Boca Raton, pp 243–244
Wöpking S, Kastrup A, Lentschig M, Brunner F (2013) Recurrent strokes due to transient vasospasms of the extracranial internal carotid artery. Case Rep Neurol 5(2):143–148. doi:10.1159/000354827
R Core Team (2015) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna
Schwarzer G (2015) Meta: general package for meta-analysis. R package version 4.3-2
Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS (2012) Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380(9849):1231–1240. doi:10.1016/s0140-6736(12)61299-9
Lee Y, Zuckerman SL, Mocco J (2013) Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand? Neurol Res Int 2013:13. doi:10.1155/2013/373458
Kuntze Soderqvist A, Kaijser M, Soderman M, Holmin S, Wahlgren N, Andersson T (2014) Mechanical thrombectomy in acute ischemic stroke-experience from 6 years of practice. Neuroradiology 56(6):477–486. doi:10.1007/s00234-014-1353-z
Higgins JP, Green S (2011) Cochrane handbook for systematic reviews of interventions. http://handbook.cochrane.org/. Accessed 7 Dec 2015
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
The manuscript does not contain clinical studies or patient data.
Conflicts of interest
Robert Emprechtinger: None. Brigitte Piso: None. Peter A Ringleb: received honoraria for advisory board participation from Boehringer Ingelheim and Covidien and lecture fee and travel support from Boehringer Ingelheim, Bayer, Pfizer, and Daiichi Sanyo.
Funding
None.
Additional information
An erratum to this article is available at http://dx.doi.org/10.1007/s00415-016-8383-x.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Emprechtinger, R., Piso, B. & Ringleb, P.A. Thrombectomy for ischemic stroke: meta-analyses of recurrent strokes, vasospasms, and subarachnoid hemorrhages. J Neurol 264, 432–436 (2017). https://doi.org/10.1007/s00415-016-8205-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00415-016-8205-1