WSO - January 2024 - 24

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International Journal of Stroke 19(1)
(95% CI: 0.61-3.18, p = 0.43) in studies that were either
matched or randomized comparisons, 1.04 (95% CI: 0.72-
1.49, p = 0.85) in studies of highest quality grade, and 1.21
(95% CI: 0.90-1.61, p = 0.20) in observational studies.
Effect of IAT on near-complete or complete
angiographic recanalization
The OR for near-complete or complete angiographic recanalization
with IAT was 0.88 (95% CI: 0.63-1.23, p = 0.46,
I2 = 69.9%, 18 studies, 8403 subjects, Figure 5(a)). A sizable
asymmetry was detected in the funnel plot. After applying
the trim and fill approach, the adjusted OR for
near-complete or complete angiographic recanalization
was significantly lower with IAT (OR: 0.59, 95% CI: 0.39-
0.88, p = 0.01; Figure 5(b)). IAT was associated with significantly
lower odds of near-complete or complete
angiographic recanalization in a fixed effect model (OR:
0.73, 95% CI: 0.62-0.85, p < 0.001). In the meta-regression,
no relationship was identified between study-level
covariates and effect size (p > 0.05). IAT was associated
with higher odds (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04)
of near-complete or complete angiographic recanalization
in studies that were either matched or randomized comparisons.
The ORs for near-complete or complete angiographic
recanalization with IAT were 0.85 (95% CI:
0.55-1.33, p = 0.48) in studies with the highest quality
grade and 0.83 (95% CI: 0.59-1.15, p = 0.26) in observational
studies.
Discussion
Salient findings
In the current systematic review and meta-analysis, we did
not identify any significant association between IAT as an
adjunct to MT and functional independence at 90 days, allcause
mortality within 90 days, or sICH. However, the
direction of association suggested a possible increase in
functional independence at 90 days (14% higher odds) and a
reduction in all-cause mortality within 90 days with IAT.
There was a trend toward higher odds of functional independence
at 90 days among patients who received IAT in
studies of the highest quality grade (24% higher odds) and
in studies that were matched or randomized comparisons
(28% higher odds). The direction of association suggested a
possible increase in the odds of post-MT sICH with IAT
although the increase was not detected when the analysis
was restricted to studies of the highest quality grade.
However, the odds increased from 19% higher (all studies)
to 39% higher in studies that were matched or randomized
comparisons. The association between IAT and near-complete
or complete angiographic recanalization demonstrated
inconsistent results. Overall, IAT was associated with lower
rates of near-complete or complete angiographic recanalization
in the fixed effect model but not in the random effects
International Journal of Stroke, 19(1)
model. IAT was associated with higher odds of near-complete
or complete angiographic recanalization in studies that
were matched or randomized comparisons. A previous
meta-analysis including 4581 patients by Chen et al.10
reported that IA treatment (thrombolytics or glycoprotein
IIb/IIIa inhibitors) was associated with a higher rate of
functional independence and another meta-analysis including
2797 patients by Kaesmacher et al.11 reported that IAT
was not associated with higher rates of functional independence
as an adjunct to MT. Inclusion of additional studies5,12-17
such as results from the randomized CHOICE17
trial in our analysis increased the sample size (7572 patients)
by almost 2-4 folds compared with the previous analyses by
Chen et al.10 and Kaesmacher et al.11 Therefore, the precision
of estimates of various outcomes was higher, and type
2 errors in comparisons were reduced. By increasing the
design diversity among included studies, we also identified
the prominent effect of design and quality of the studies on
the association between IAT and functional independence at
90 days.
Current perception of IAT as adjunct to MT
IAT continues to be used frequently in an inconsistent manner
as an adjunct to MT in AIS patients. Over 60% of
respondents used IAT with MT without any clear consensus
on its indications or therapeutic value in a survey of 104
neurointerventionalists.39 Of those who used IAT, 60.4%
indicated that they used IAT for: (1) treating a primary distal
occlusion, (2) as rescue therapy, and/or (3) adjunctive therapy.
Almost half (49.4%) of those surveyed believed that
IAT may have a role with MT, but more evidence is needed,
while 37.6% agreed that IAT has a role in MT. Only 12.9%
felt there was no role for IAT in modern endovascular practice.
A survey of 99 neurologists and neurointerventionalists
from all German University hospitals, all participants of the
German Stroke Registry-Endovascular Treatment (GSR),
found that IAT was used in select cases by 39% and as a
standard of care by 3% of the respondents.40 We surveyed
individuals who were part of the ACTION CVT (Direct
Oral Anticoagulants Versus Warfarin in the Treatment of
Cerebral Venous Thrombosis) group, Life journal authors of
stroke-related publications, ASPIRE (Anticoagulation in
ICH Survivors for Stroke Prevention and Recovery) clinical
trial, COVID-19 stroke project, SVIN (Society of Vascular
and Interventional Neurology) task force on trainee education,
and Endovascular Stroke Treatment Optimization
(ESTO)-2 investigators (unpublished data). A total of 92
(63%) of 146 respondents reported they followed no specific
protocol on who received IAT, but 79% reported using
IAT with MT. A total of 82 (56.1%) respondents stated that
they would classify the importance of determining the therapeutic
value of IAT during MT as very important or important.
A total of 135 (92.5%) stated that they would definitely,
very probably, or probably modify their practice if a
WSO - January 2024

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