Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials

Mayank Goyal, Bijoy K. Menon, Wim H. van Zwam, Diederik W. J. Dippel, Peter J. Mitchell, Andrew M. Demchuk, Antoni Davalos, Charles B. L. M. Majoie, Aad van der Lugt, Maria A. de Miquel, Geoff Rey A. Donnan, Yvo B. W. E. M. Roos, Alain Bonafe, Reza Jahan, Hans-Christoph Diener, Lucie A. van den Berg, Elad I. Levy, Olvert A. Berkhemer, Vitor M. Pereira, Jeremy RempelMonica Millan, Stephen M. Davis, Daniel Roy, John Thornton, Luis San Roman, Marc Ribo, Debbie Beumer, Bruce Stouch, Scott Brown, Bruce C. V. Campbell, Robert J. van Oostenbrugge, Jeff Rey L. Saver, Michael D. Hill, Tudor G. Jovin*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

3294 Citations (Web of Science)

Abstract

Background In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included. Methods We formed the HERMES collaboration to pool patient-level data from five trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) done between December, 2010, and December, 2014. In these trials, patients with acute ischaemic stroke caused by occlusion of the proximal anterior artery circulation were randomly assigned to receive either endovascular thrombectomy within 12 h of symptom onset or standard care (control), with a primary outcome of reduced disability on the modified Rankin Scale (mRS) at 90 days. By direct access to the study databases, we extracted individual patient data that we used to assess the primary outcome of reduced disability on mRS at 90 days in the pooled population and examine heterogeneity of this treatment effect across prespecified subgroups. To account for between-trial variance we used mixed-effects modelling with random effects for parameters of interest. We then used mixed-effects ordinal logistic regression models to calculate common odds ratios (cOR) for the primary outcome in the whole population (shift analysis) and in subgroups after adjustment for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale score), site of occlusion (internal carotid artery vs M1 segment of middle cerebral artery vs M2 segment of middle cerebral artery), intravenous alteplase (yes vs no), baseline Alberta Stroke Program Early CT score, and time from stroke onset to randomisation. Findings We analysed individual data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control). Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted cOR 2.49, 95% CI 1.76-3.53; p
Original languageEnglish
Pages (from-to)1723-1731
JournalLancet
Volume387
Issue number10029
DOIs
Publication statusPublished - 23 Apr 2016

Cite this