AUTHOR=Ye Gengfan , Cao Ruoyao , Chen Pandi , Wang Hongcai , Wang Dongfeng , Chen Maosong , Li Zhenqiang 

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

JOURNAL=Frontiers in Neurology

VOLUME=Volume 14 - 2023

YEAR=2023

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1279233

DOI=10.3389/fneur.2023.1279233

ISSN=1664-2295

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-analyses 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 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%). 

Conclusions
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.