Network meta-analysis of first-line thrombectomy strategy for acute posterior circulation strokes: a preliminary evaluation for combined approach

Gengfan Ye; Ruoyao Cao; Pandi Chen; Hongcai Wang; Dongfeng Wang; Maosong Chen; Zhenqiang Li

doi:10.3389/fneur.2023.1279233

Network meta-analysis of first-line thrombectomy strategy for acute posterior circulation strokes: a preliminary evaluation for combined approach

Front Neurol. 2023 Nov 3:14:1279233. doi: 10.3389/fneur.2023.1279233. eCollection 2023.

Authors

Gengfan Ye^#¹, Ruoyao Cao^#^{2

3}, Pandi Chen¹, Hongcai Wang¹, Dongfeng Wang¹, Maosong Chen^#¹, Zhenqiang Li^#¹

Affiliations

¹ Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China.
² Department of Radiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.
³ Graduate School of Peking Union Medical College, Beijing, China.

^# Contributed equally.

Abstract

Objective: Thrombectomy may provide superior results compared to best medical care for acute posterior circulation strokes (PCS). Contact aspiration (CA), stent retriever (SR), and combined SR + CA (SRA) are commonly employed as first-line techniques. However, the optimal strategy and the role of SRA remain uncertain.

Methods: Systematic searching was conducted in three databases (PubMed, Embase, and Cochrane). Network meta-analyzes were performed using random-effects models. The reperfusion and clinical outcomes were compared. Pooled outcomes were presented as odds ratios (OR) with 95% confidence intervals (CI). Rankograms with surface under the cumulative ranking curve (SUCRA) were calculated.

Results: Seventeen studies were included, involving a total of 645 patients who received first-line CA, 850 patients who received SR, and 166 patients who received SRA. Regarding final recanalization outcomes, both first-line SRA (OR = 3.2, 95%CI 1.4-11.0) and CA (OR = 2.1, 95%CI 1.3-3.7) demonstrated superiority over SR in achieving successful reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3], with values of SUCRA 91.1, 58.5, and 0.4%, respectively. In addition, first-line SRA showed an advantage in achieving final mTICI 2c/3 compared to CA (OR = 3.6, 95%CI 0.99-16.0) and SR (OR = 6.4, 95%CI 1.3-35.0), with SUCRA value of 98.0, 44.7, and 7.2%, respectively. Regarding reperfusion outcome after the first pass, SRA also achieved a higher rate of mTICI 3 than SR (OR = 4.1, 95%CI 1.3-14.0), while CA did not (SUCRA 97.4, 4.6, 48.0%). In terms of safety outcomes, first-line CA was associated with a lower incidence of symptomatic intracranial hemorrhage (sICH) compared to SR (OR = 0.38, 95%CI 0.1-1.0), whereas the SRA technique did not (SUCRA 15.6, 78.6, 55.9%). Regarding clinical prognosis, first-line CA achieved a higher proportion of functional independence (modified Rankin Scale (mRS) 0-2) at 90 days than SR (OR = 1.4, 95%CI 1.1-1.9), whereas SRA did not (SUCRA 90.5, 17.4, 42.1%).

Conclusion: For acute PCS, a first-line CA strategy yielded better results in terms of final successful reperfusion and 90-day functional independence compared to SR. As the combined technique, first-line SRA was associated with superior first-pass and final reperfusion outcomes compared to SR. However, no significant difference was observed in functional independence achieved by first-line SRA compared to the other two strategies. Further high-quality studies are warranted.

Keywords: aspiration; combined technique; frontline strategy; posterior circulation; stent retriever; stroke.

Publication types

Systematic Review

Grants and funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the following grants: the project of NINGBO Leading Medical and Health Discipline [2022-F04], the Ningbo Natural Science Foundation [No. 2021 J284], the Ningbo Municipal Bureau of Science and Technology [2021S172], the Ningbo Medical Science and Technology Project [2020Y02].