Table_3_Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.DOCX

Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection.
Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b−3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0–2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle–Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I2 statistic. Subgroup and sensitivity analyses were also performed.
Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40–0.99, p = 0.04]. 90-day favorable outcome (mRS 0–2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58–0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups.
Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results.
Systematic Review Registration: “PROSPERO” database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.

背景：由颅内-颅外串联闭塞所致的急性缺血性脑卒中（Acute ischemic stroke, AIS）并非罕见。但顺行入路（先处理颅外病变）与逆行入路（先处理颅内病变）这两种治疗策略的最优选择仍不明确。本系统评价与荟萃分析旨在对比两种入路策略，为治疗方案的选择提供最新临床证据。
方法：检索PubMed数据库、Ovid平台、Web of Science数据库及Cochrane图书馆中，对比急性缺血性脑卒中合并串联闭塞患者采用顺行与逆行入路的相关文献。评估的结局指标包括成功再灌注[脑梗死溶栓（Thrombolysis in Cerebral Infarction, TICI）分级2b~3级]、90天良好预后[改良Rankin量表（modified Rankin Scale, mRS）评分0~2分]、任何颅内出血、症状性颅内出血、操作相关并发症及死亡率。采用纽卡斯尔-渥太华量表（Newcastle–Ottawa Scale）评估偏倚风险，并通过漏斗图呈现结果；采用I²统计量评估异质性，同时开展亚组分析与敏感性分析。
结果：最终纳入11项研究，共1517例患者。其中831例（55%）采用顺行入路治疗，686例（45%）采用逆行入路治疗。逆行入路组的成功再灌注率显著高于顺行入路组[83.8% vs. 78.0%；比值比（odds ratio, OR）=0.63，95%置信区间（confidence interval, CI）：0.40~0.99，P=0.04]。逆行入路组的90天良好预后（90天mRS评分0~2分）比例亦显著高于顺行入路组（47.3% vs. 40.2%；OR=0.72，95%CI：0.58~0.89，P=0.002）。两组在任何颅内出血、症状性颅内出血、90天死亡率及其他并发症的发生率上均无显著差异。
结论：对于合并串联闭塞的急性缺血性脑卒中患者，与顺行入路相比，逆行入路可获得更高的成功再灌注率及更优的功能预后，且安全性相当。未来仍需开展设计更严谨、证据等级更高的前瞻性对照研究以验证本研究结果。
系统评价注册："PROSPERO"数据库（CRD 42020199093），网址：https://www.crd.york.ac.uk/PROSPERO/。