Introduction

Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment.

Methods

Systematic review followed predefined protocol (Open-Science-Framework osf.io/bfykj). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment.

Results

Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (n = 450) did not differ for favorable outcome and mortality compared to EVT (n = 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2–0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3–3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1–3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1–4.4) but similar mortality rates.

Conclusions

Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.

中文翻译：

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孤立性颈内动脉闭塞所致卒中的再灌注策略：系统评价和治疗比较

介绍

尽管静脉溶栓 (IVT) 和血管内治疗 (EVT) 已被证明对大血管闭塞引起的急性缺血性卒中 (AIS) 有效，但仍然没有确凿的数据来指导颈内动脉 (ICA) 闭塞引起的卒中治疗. 我们系统地回顾了现有文献以比较 IVT、EVT 和桥接（IVT + EVT）并定义最佳治疗。

方法

系统审查遵循预定义的协议 (Open-Science-Framework osf.io/bfykj)。检索了 MEDLINE、EMBASE 和 Cochrane CENTRAL。结果仅限于英语研究，样本量≥10，随访时间≥30 天。主要结局是良好结局（mRS ≤ 2）、死亡率和症状性脑出血（sICH），根据研究原始报告进行定义。纽卡斯尔-渥太华量表用于偏差评估。

结果

荟萃分析中纳入了 930 条筛选记录的 7 条记录。5 项研究质量低至一般，2 项良好。与 EVT ( n = 150)相比，IVT ( n = 450) 在有利结果和死亡率方面没有差异，尽管 sICH 发生率较低（OR = 0.4， 95% 置信区间 0.2–0.8)。与 IVT 相比，桥接 (IVT + EVT) 与更高的良好结局率相关（OR = 2.2，95% CI 1.3–3.7）。与 EVT 相比，桥接 (IVT + EVT) 提供更高的有利结果率（OR = 1.9，95% CI 1.1-3.4），sICH 风险略有增加（OR = 2.1，95% CI 1-4.4）但相似死亡率。

结论

我们的系统评价强调，在与孤立性颈椎 ICA 闭塞相关的急性缺血性卒中中，桥接（IVT + EVT）可能会导致随访时更高的功能独立率，而不会增加死亡率。现有研究的低质量阻碍了得出确切结论，因此迫切需要随机对照临床试验来确定该 AIS 亚组的最佳治疗方法。