Safety and efficacy of intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation.

BACKGROUND: Intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is the standard treatment for patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). However, the efficacy and safety of IVT before EVT in AIS-LVO patients with atrial fibrillation (AF) remains controversial. Thus, this study aims to assess the benefit of IVT plus EVT and direct EVT alone in AIS-LVO patients with AF. METHOD: Relevant studies that evaluated the outcomes of IVT plus EVT versus direct EVT alone in AIS-LVO patients with AF were systematically searched in PubMed, Embase, and Cochrane Library from inception to August 10, 2023. The outcomes included successful reperfusion (score of 2b to 3 for thrombolysis in cerebral infarction), symptomatic intracerebral hemorrhage (sICH), good clinical outcome (modified Rankin scale score ≤ 2) at 3 months, and 3-month mortality. RESULT: Eight eligible observational studies involving 6998 (3827 in the IVT plus EVT group and 3171 in the direct EVT group) patients with AIS-LVO complicated by AF were included. Compared with direct EVT, IVT plus EVT resulted in better 3-month clinical outcomes (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.05-1.54) and lower 3-month mortality (OR 0.78, 95% CI 0.68-0.88). However, the incidence of sICH (OR 1.26, 95% CI 0.91-1.75) and the rate of successful reperfusion (OR 0.98, 95% CI 0.83-1.17) were not significantly different between treatment modalities. CONCLUSION: IVT plus EVT leads to better functional outcomes and lower mortality in AIS-LVO patients with AF. Withholding IVT plus EVT from patients with AF alone may not be justified.

Intravenous thrombolysis in acute ischemic stroke patients with pre-stroke disability: A systematic review and meta-analysis.

BACKGROUND: Intravenous thrombolysis (IVT), which is safe and effective, is the first-line therapy for acute ischemic stroke (AIS). However, its benefit for AIS patients with pre-stroke disability (PSD) is controversial. OBJECTIVE: We determined the association of PSD with the safety and efficacy of IVT among patients with AIS. METHODS: We searched PubMed, Embase, and the Cochrane Library from inception to May 23, 2022. The articles focusing on outcomes of AIS patients with PSD receiving IVT were retrieved. We used the random-effects model to pool outcomes including mortality, 24 h NIHSS improvement, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome (FFO), the favorable outcome, and mortality prevalence. RESULTS: Ten studies (including 245,773 participants) that reported the outcomes of AIS patients with PSD undergoing IVT were included. In unadjusted analyses, PSD was associated with mortality (10 studies; odds ratio [OR] 1.739, 95% confidence interval [CI], 1.336-2.407), FFO (7 studies; OR 1.057, 95% CI, 1.015-1.100), 24 h NIHSS improvement (5 studies; OR .840, 95% CI, .819-.917, p = .000), and sICH (9 studies; OR .773, 95% CI, .481-1.243). In adjusted analyses, PSD was associated with mortality (seven studies; ORadj 1.789, 95% CI, 1.413-2.264), FFO (five studies; ORadj 1.087, 95% CI, 1.002-1.179), 24 h NIHSS improvement (five studies; ORadj .837, 95% CI, .799-.876), and sICH (five studies; ORadj .857, 95% CI, .725-1.012). The prevalence of FFO and mortality in patients with pre-stroke modified Rankin Scale scores of 2-5 were 49% (0.42-0.56) and 37% (0.21-0.53), respectively. CONCLUSIONS: Patients with PSD undergoing IVT had a higher mortality rate than those without PSD. Meanwhile, PSD was associated with FFO, and there was no significant difference in sICH and 24 h NIHSS improvement. High-quality data are needed to clarify the benefits of administering IVT in these patients.

Real-world safety and efficacy endovascular treatment versus standard medical treatment for basilar artery occlusion: A systematic review and meta-analysis.

PURPOSE: We acknowledge that between endovascular treatment (EVT) has emerged as a promising therapeutic approach, with some evidence of benefits observed in clinical trials. However, there remains a significant gap in the evidence regarding the real-world application and effectiveness of EVT.The objective of this study was to comprehensively evaluate the safety and efficacy differences between EVT and standard medical treatment (SMT) in patients with basilar artery occlusion(BAO). METHODS: Real-world studies (RWSs) on patients with BAO who underwent EVT and SMT were identified through searches in EMBASE, PubMed, and Cochrane Library databases. The efficacy outcomes included good clinical outcomes [defined as modified Rankin Scale (mRS) scores of 0-3 at 90 days], excellence clinical outcomes (defined as mRS scores of 0-2 at 90 days), 90-day mortality rate, and reperfusion status. The safety outcome was symptomatic intracranial hemorrhage (sICH). Subgroup analysis was conducted based on study type (prospective and retrospective studies). The relationship between EVT and SMT with the prognosis of BAO patients was expressed using odds ratios (OR) with a 95% confidence interval (95% CI). RESULTS: The seven studies involved a total of 2885 patients. After conducting sensitivity analysis and excluding articles with high heterogeneity, EVT demonstrated a significant association with good clinical outcomes at 90 days (OR=4.01, 95% CI: 2.60-6.19) and excellence clinical outcomes at 90 days (OR=5.70, 95% CI: 3.18-10.22) compared to SMT. Additionally, EVT showed a lower correlation with 90-day mortality rate compared to the SMT group (OR=0.35, 95% CI: 0.25-0.47). Subgroup analysis based on study type revealed that EVT had higher rates of successful reperfusion (retrospective study group: OR=7.97, 95% CI: 4.83-13.15; prospective study group: OR=51.57, 95% CI: 29.76-89.38) than the SMT group in both subgroups. The presence of sICH was not statistically significant in the retrospective study group (OR=1.20, 95% CI: 0.58-2.48) and showed high heterogeneity. However, in the prospective study group, EVT exhibited a higher risk of bleeding compared to SMT (OR=11.42, 95% CI: 2.65-49.20). CONCLUSIONS: In summary, our real-world study aligns with the conclusions of recently published randomized controlled trials research. When comparing EVT and SMT in the treatment of BAO, EVT shows a higher correlation with favorable clinical outcomes, higher rates of successful reperfusion, and lower mortality rates. However, it does come with an increased risk of sICH.

Implications of frailty in acute ischemic stroke receiving endovascular treatment: systematic review and meta-analysis.

BACKGROUND: Frailty is a state of cumulative degeneration of bodily functions that is consistently associated with poor outcomes in older people following illness. Combined stroke intervention and frailty may yield additive and synergistic effects adults with stroke. OBJECTIVE: To evaluate the safety and efficacy of endovascular therapy (EVT) in frail patients. METHODS: We conducted a systematic review of the relationship between debilitation and acute ischemic stroke (AIS) after EVT. Until August 2022, researchers have searched three databases (Pubmed, EMBASE and Cochrane). Random-effects meta-analysis, combined ratio (OR) and 95% confidence interval (95%CI) were used to assess efficacy values. The I2 statistic was used to assess heterogeneity. Comprehensive meta-analysis software was used for meta-analysis. RESULTS: We ultimately included eight studies including 3662 non-overlapping participants. Four studies used the Clinical Frailty Scale (CFS), two studies used the Hospital Frailty Risk Score (HFRS), a study used frailty index and a study used the comprehensive geriatric assessment (CGA). Frailty prevalence: 35%; 95% CI, 0.27-0.43; low quality evidence, downgraded due to heterogeneity, bias. Random effects showed that poor functional outcome (5 studies, OR 1.956, 95% CI 1.256-3.048) and mortality (9 studies, OR 2.320, 95% CI 1.680-3.205) was significantly associated with frailty. In adjusted analyses, poor functional outcome (4 studies, ORadj 1.189, 95% CI 1.043-1.357), and mortality (3 studies, ORadj 1.036, 95% CI 1.008-1.065) were significantly associated with frailty. CONCLUSION: Pre-stroke frailty is an important predictor of poor prognosis assessed by EVT and can be added to the classical predictors of stroke outcome. Routine assessment of pre-stroke frailty can help patients to make decisions about the efficacy of their choice of EVT.

Clinical Significance of Plasma D-Dimer and Fibrinogen in Outcomes after Stroke: A Systematic Review and Meta-Analysis.

BACKGROUND: There is increasing evidence on the prognostic significance of D-dimer and fibrinolysis in stroke. However, the systematic analysis of their relationship with adverse outcomes after stroke is lacking. Herein, we comprehensively assessed the correlation of D-dimer and fibrinolysis with stroke outcomes through meta-analysis. METHODS: Studies for systematic literature review were retrieved from PubMed, EMBASE, and Cochrane Library databases. The association of D-dimer and fibrinolysis with outcomes of stroke patients was expressed as an odds ratio (OR) with 95% confidence intervals (95% CI). RESULTS: Totally, 52 studies comprising 21,473 stroke patients were included. The results showed that the high D-dimer level was significantly associated with peripheral venous thrombosis after stroke (OR 1.03, 95% CI 1.01-1.05), poor outcome (MRS >2) after stroke (OR 1.731, 95% CI 1.464-2.048), death after stroke (OR 2.367, 95% CI 1.737-3.224), stroke recurrence (OR 1.229, 95% CI 1.113-1.358), and early neurologic deterioration (NIHSS >4) (OR 1.791, 95% CI 1.117-2.870). Moreover, high fibrinogen level was significantly associated with poor outcome (MRS >2) after stroke (OR 1.650, 95% CI 1.314-2.071), death after stroke (OR 1.310, 95% CI 1.128-1.520), stroke recurrence (OR 1.228, 95% CI 1.166-1.422), early neurologic deterioration (NIHSS >4) (OR 2.381, 95% CI 1.156-4.904), and coronary events after stroke (OR 1.427, 95% CI 1.232-1.653). CONCLUSION: Fibrinogen and D-dimer may be associated with adverse outcomes in patients with stroke, suggesting that they may serve as possible biomarkers for post-stroke adverse outcomes.

Endovascular thrombectomy in acute ischemic stroke patients with prestroke disability (mRS ≥2): A systematic review and meta-analysis.

Objective: The effect of endovascular thrombectomy (EVT) in acute ischemic stroke patients with prestroke disability (modified Rankin Scale score, mRS) ≥2) has not been well-studied. This study aimed to assess the safety and benefit of EVT in patients with prestroke disability. Methods: According to PRISMA guidelines, literature searching was performed using PubMed, Embase, and Cochrane databases, for a series of acute ischemic stroke patients with prestroke mRS ≥2 treated by EVT. Random-effects meta-analysis was used to pool the rate of return to prestroke mRS and mortality at 3-month follow-up. Results: In total, 13 observational studies, with 2,625 patients, were analyzed. The rates of return to prestroke mRS in patients with prestroke mRS of 2-4 were 20% (120/588), 27% (218/827), and 31% (34/108), respectively. Patients with prestroke disability treated by EVT had a higher likelihood of return to prestroke mRS (relative risk, RR, 1.86; 95% CI 1.28-2.70) and a lower likelihood of mortality (RR 0.75; 95%CI 0.58-0.97) compared with patients with standard medical treatment. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) after EVT gave a higher likelihood of return to prestroke mRS (RR 2.04; 95% CI 1.17-3.55) and lower mortality (RR 0.72; 95% CI 0.62-0.84) compared with unsuccessful reperfusion. Conclusions: Acute ischemic stroke patients with prestroke disability may benefit from EVT. Withholding EVT on the sole ground of prestroke disabilities may not be justified.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.

Environmental toxic metal contaminants and risk of stroke: a systematic review and meta-analysis.

The relationship between toxic metals in the environment and clinical stroke risk remains unclear, although their role as immunotoxicants and carcinogens has been well established. We conducted a systematic review of the relationship between five metals (arsenic, mercury, copper, cadmium, and lead) and stroke. First, we comprehensively searched 3 databases (Pubmed, EMBASE, and Cochrane) from inception until June 2021. Random-effects meta-analyses, pooled relative risks (RR) and 95% confidence intervals (CI) were applied to evaluate the effect value. We finally identified 38 studies involving 642,014 non-overlapping participants. Comparing the highest vs. lowest baseline levels, chronic exposure to lead (RR = 1.07; 95%CI,1.00-1.14), cadmium (RR = 1.30; 95%CI,1.13-1.48), and copper (RR = 1.19; 95%CI,1.04-1.36) were significantly associated with stroke risks. However, the other two metals (arsenic and mercury) had less effect on stroke risk. Further analysis indicated that the association was likely in a metal dose-dependent manner. The results may further support the possibility that environmental toxic metal contaminants in recent years are associated with the increased risk of stroke.

Statin Use and Outcomes of Patients With Acute Ischemic Stroke Treated With Intravenous Thrombolysis: A Systematic Review and Meta-Analysis.

Background: The data on the relationship between statin use and clinical outcomes after intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) are in controversy. Objective: This systematic review and meta-analysis aimed to evaluate the safety and efficacy of statins administered prior to onset and during hospitalization in patients with AIS treated with IVT. Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception until June 8, 2021. Comparative studies investigating statin effect on intracranial hemorrhage (ICH), functional outcomes, and mortality in adults with AIS treated with IVT were screened. Random-effect meta-analyses of odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were performed. The protocol was registered in PROSPERO (CRD42021254919). Results: Twenty-two observational studies were included, which involved 17,554 patients. The pooled estimates showed that pre-stroke statin use was associated with a higher likelihood of symptomatic ICH (OR 1.31; 95% CI 1.07-1.59; p = 0.008) and any ICH (OR 1.21; 95% CI 1.03-1.43; p = 0.02). However, the pre-stroke statin use was not significantly associated with the 3-month mortality, 3-month favorable functional outcome (FFO, modified Rankin Scale [mRS] score 0-1), and 3-month functional independence (FI; mRS score 0-2). However, in-hospital statin use was associated with a reduced risk of symptomatic ICH (OR 0.46; 95% CI 0.21-1.00; p = 0.045), any ICH (OR 0.51; 95% CI 0.27-0.98; p = 0.04), and 3-month mortality (OR 0.42; 95% CI 0.29-0.62; p < 0.001) and an increased probability of 3-month FFO (OR 1.33; 95% CI 1.02-1.744; p = 0.04) and 3-month FI (OR 1.41; 95% C, 1.11-1.80; p = 0.005). Conclusions: The present systematic review and meta-analysis suggests that in-hospital statin use after IVT may be safe and may have a favorable impact on clinical outcomes, a finding not observed in studies restricted to patients with pre-stroke statin use.

Tranexamic Acid for Acute Spontaneous Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials.

Background: The role of tranexamic acid (TXA) in preventing hematoma expansion (HE) in patients with acute spontaneous intracerebral hemorrhage (ICH) remains unclear. We aim to investigate the efficacy and safety of TXA in acute spontaneous ICH with a particular focus on subgroups. Methods: Randomized controlled trials (RCTs) were retrieved from CENTRAL, Clinicaltrials.gov, EMBASE, PubMed, and WHO ICTRP. The primary outcome measurement was HE. The secondary outcome measurements included 3-month poor functional outcome (PFO), 3-month mortality, and major thromboembolic events (MTE). We conducted subgroup analysis according to the CT markers of HE (standard-risk population and high-risk population) and the time from onset to randomization (>4.5 and ≤4.5 h). Results: We identified seven studies (representing five RCTs) involving 2,650 participants. Compared with placebo, TXA may reduce HE on subsequent imaging (odd ratio [OR] 0.825; 95% confidence interval [CI] 0.692-0.984; p = 0.033; I2 = 0%; GRADE: moderate certainty). TXA and placebo arms did not differ in the rates of 3-month PFO, 3-month mortality, and MTE. Subgroup analysis indicated that TXA reduced the risk of HE in the high-risk population with CT markers of HE (OR 0.646; 95% CI 0.503-0.829; p = 0.001; I2 = 0 %) and in patients who were treated within 4.5 h of symptom onset (OR 0.823; 95% CI 0.690-0.980; p = 0.029; I2 = 0%), but this protective effect was not observed in the standard-risk population and patients who were treated over 4.5 h of symptom onset. Conclusions: Tranexamic acid (TXA) may decrease the risk of HE in patients with acute spontaneous ICH. Importantly, the decreased risk was observed in patients who were treatable within 4.5 h and with a high risk of HE, but not in those who were treatable over 4.5 h and in standard-risk population. However, PFO or mortality at 3 months did not significantly differ between patients who received TXA and those who received placebo. TXA is safe for acute spontaneous ICH without increasing MTE.