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Shafique MA, Ali SMS, Mustafa MS, Aamir A, Khuhro MS, Arbani N, Raza RA, Abbasi MB, Lucke-Wold B. Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion. Clin Neurol Neurosurg 2024; 236:108070. [PMID: 38071760 DOI: 10.1016/j.clineuro.2023.108070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone. METHOD We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies. RESULT 76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0-1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66-0.86; p < 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25-1.65; p < 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621-1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594-0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity. CONCLUSION Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.
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Affiliation(s)
| | | | | | - Ali Aamir
- Department of Medicine, Dow University of Health Sciences, Pakistan.
| | | | - Naeemullah Arbani
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
| | - Rana Ali Raza
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
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2
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Zheng M, Li L, Chen L, Li B, Feng C. Mechanical thrombectomy combined with intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analyses. Sci Rep 2023; 13:8597. [PMID: 37237159 DOI: 10.1038/s41598-023-35532-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
To assess the clinical value of mechanical thrombectomy (MT) combined with intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) by comparing it with the MT alone. In this study, we conducted a comprehensive meta-analysis of both observational and randomized controlled studies (RCTs) to investigate various outcomes. Our search for relevant studies was conducted between January 2011 and June 2022 in four major databases: PubMed, Embase, WOS, and Cochrane Library. We collected data on several outcomes, including functional independence (FI; defined as modified Rankin Scale score of 0 to 2), excellent outcomes (mRS 0-1), successful recanalization (SR), symptomatic intracerebral hemorrhage (sICH), any intracerebral hemorrhage (aICH), and mortality at three months or discharge. The primary efficacy outcome and safety outcome were FI and sICH, respectively, whereas excellent outcomes and SR were considered secondary efficacy outcomes. Additionally, mortality and aICH were analyzed as secondary safety outcomes. We employed the Mantel-Haenszel fixed-effects model for RCTs when I2 < 50%, otherwise the random-effects model was utilized. For observational studies and subgroup analyses, we used the random-effects model to minimize potential bias. A total of 55 eligible studies (nine RCTs and 46 observational studies) were included. For RCTs, the MT + IVT group was superior in FI (OR: 1.27, 95% CI: 1.11-1.46), excellent outcomes (OR: 1.21, 95% CI: 1.03-1.43), SR (OR: 1.23, 95% CI: 1.05-1.45), mortality (OR: 0.72, 95% CI: 0.54-0.97) in crude analyses. In adjusted analyses, the MT + IVT group reduced the risk of mortality (OR: 0.65, 95% CI: 0.49-0.88). However, the difference in FI between the MT + IVT group and the MT alone group was not significant (OR: 1.17, 95% CI: 0.99-1.38, Fig. 3a). For observational studies, the results of FI (OR: 1.34, 95% CI: 1.16-1.33), excellent outcomes (OR: 1.30, 95% CI: 1.09-1.54), SR (OR: 1.23, 95% CI: 1.05-1.44), mortality (OR: 0.70, 95% CI: 0.64-0.77) in the MT + IVT group were better. Additionally, the MT + IVT group increased the risk of hemorrhagic transformation (HT) including sICH (OR: 1.16, 95% CI: 1.11-1.21) and aICH (OR: 1.24, 95% CI: 1.05-1.46) in crude analyses. In adjusted analyses, significant better outcomes were seen in the MT + IVT group on FI (OR: 1.36, 95% CI: 1.21-1.52), excellent outcomes (OR: 1.49, 95% CI: 1.26-1.75), and mortality (OR: 0.73, 95% CI: 0.56-0.94). The MT + IVT therapy did improve the prognosis for AIS patients and did not increase the risk of HT compared with MT alone therapy.
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Affiliation(s)
- Meiling Zheng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, People's Republic of China
| | - Li Li
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan Province, People's Republic of China.
| | - Lizhou Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Bin Li
- Department of Geriatrics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, People's Republic of China.
| | - Cuiling Feng
- Peking University People's Hospital, Beijing, 100000, People's Republic of China.
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3
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Hyperdense middle cerebral artery sign predicts favorable outcome in patients undergoing mechanical thrombectomy. J Thromb Thrombolysis 2023; 55:312-321. [PMID: 36434302 DOI: 10.1007/s11239-022-02731-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/26/2022]
Abstract
Non-contrast computer tomography detects the presence of hyperdense middle cerebral artery sign (HMCAS). Studies on the prognostic value of HMCAS among patients undergoing mechanical thrombectomy (MT) are conflicting. A retrospective analysis of consecutive patients with acute ischemic stroke due to middle cerebral artery occlusion, presenting with or without HMCAS, who underwent MT, was performed. We enrolled 191 patients (HMCAS +, n = 140; HMCAS -, n = 51). Prevalence of successful recanalization was significantly higher in patients with HMCAS than in those without HMCAS (92.1% versus 74.5%, p = 0.001). Patients with HMCAS had a better clinical outcome than those HMCAS - (54.3% versus 37.3%, p = 0.037, for three-month favorable outcome; 62.9% versus 39.3%, p = 0.004, for major neurological improvement at discharge; 8.6% versus 19.6%, p = 0.035, for in-hospital mortality; 14.3% versus 27.5%, p = 0.035, for intracranial hemorrhage; 2.9% versus 17.6%, p = 0.001, for symptomatic intracranial hemorrhage). Multivariate analyses confirmed that HMCAS represents an independent predictor of three-month favorable outcome (OR 2.48, 95% CI 1.10-5.58, p = 0.028), major neurological improvement at discharge (OR 2.40, 95% CI 1.09-5.20, p = 0.030), in-hospital mortality (OR 0.29, 95% CI 0.010-0.81, p = 0.018), presence of ICH (OR 0.49, 95% CI 0.25-0.97, p = 0.042) and presence of SICH (OR 0.16, 95% CI 0.04-0.63, p = 0.009). HMCAS presence predicts favorable outcome in patients undergoing MT. This result may indicate that hyperdense clots are more likely to respond to MT than isodense ones. This effect is mediated by reduction in hemorrhagic transformation.
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4
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Intravenous thrombolysis before mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion; should we cross that bridge? A systematic review and meta-analysis of 36,123 patients. Neurol Sci 2022; 43:6243-6269. [DOI: 10.1007/s10072-022-06283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 10/16/2022]
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5
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Merlino G, Pez S, Gigli GL, Sponza M, Lorenzut S, Surcinelli A, Smeralda C, Valente M. Stress Hyperglycemia in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Undergoing Mechanical Thrombectomy. Front Neurol 2021; 12:725002. [PMID: 34659090 PMCID: PMC8511418 DOI: 10.3389/fneur.2021.725002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/30/2021] [Indexed: 01/08/2023] Open
Abstract
Stress hyperglycemia may impair outcomes in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). The glucose-to-glycated hemoglobin ratio (GAR) was used to measure stress hyperglycemia. Data from our database of consecutive patients admitted to the Udine University Hospital with AIS who were treated with MT between January 2015 and December 2020 were retrospectively analyzed. We included 204 patients in the study and stratified them into four groups according to the quartiles of GAR (Q1-Q4). The higher the GAR index, the more severe the stress hyperglycemia was considered. Patients with more severe stress hyperglycemia showed a higher prevalence of 3-month poor outcome (Q1, 53.1%; Q2, 40.4%; Q3, 63.5%; Q4, 82.4%; p = 0.001), 3-month mortality (Q1, 14.3%; Q2, 11.5%; Q3, 15.4%; Q4, 31.4%; p = 0.001), and symptomatic intracranial hemorrhage (Q1, 2%; Q2, 7.7%; Q3, 7.7%; Q4, 25.4%; p = 0.001). After controlling for several confounders, severe stress hyperglycemia remained a significant predictor of 3-month poor outcome (OR 4.52, 95% CI 1.4-14.62, p = 0.012), 3-month mortality (OR 3.55, 95% CI 1.02-12.29, p = 0.046), and symptomatic intracranial hemorrhage (OR 6.89, 95% CI 1.87-25.36, p = 0.004). In summary, stress hyperglycemia, as measured by the GAR index, is associated with a detrimental effect in patients with AIS undergoing MT.
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Affiliation(s)
- Giovanni Merlino
- Stroke Unit, Department of Neuroscience, Udine University Hospital, Udine, Italy.,Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Sara Pez
- Clinical Neurology, Udine University Hospital, Udine, Italy.,Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology, Udine University Hospital, Udine, Italy.,Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| | - Massimo Sponza
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Stroke Unit, Department of Neuroscience, Udine University Hospital, Udine, Italy
| | - Andrea Surcinelli
- Clinical Neurology, Udine University Hospital, Udine, Italy.,Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| | - Carmelo Smeralda
- Clinical Neurology, Udine University Hospital, Udine, Italy.,Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology, Udine University Hospital, Udine, Italy.,Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
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6
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Ding HJ, Ma C, Ye FP, Zhang JF. Bridging therapy and direct mechanical thrombectomy in the treatment of cardiogenic cerebral infarction with anterior circulation macrovascular occlusion. World J Clin Cases 2021; 9:8051-8060. [PMID: 34621862 PMCID: PMC8462204 DOI: 10.12998/wjcc.v9.i27.8051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis is an important treatment for cerebral infarction. However, it is difficult to achieve good results if the patient is complicated with anterior circulation macrovascular occlusion. In addition, the vascular recanalization rate is low, so mechanical thrombectomy, that is, bridging therapy, is needed
AIM To investigate the efficacy and safety of bridging therapy and direct mechanical thrombectomy in the treatment of cardiogenic cerebral infarction with anterior circulation macrovascular occlusion.
METHODS Ninety-six patients in our hospital with cardiogenic cerebral infarction with anterior circulation macrovascular occlusion from January 2017 to July 2020 were divided into a direct thrombectomy group (n = 48) and a bridging group (n = 48). Direct mechanical thrombectomy was performed in the direct thrombectomy group, and bridging therapy was used in the bridging treatment group. Comparisons were performed for the treatment data of the two groups (from admission to imaging examination, from admission to arterial puncture, from arterial puncture to vascular recanalization, and from admission to vascular recanalization), vascular recanalization rate, National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) scores before and after treatment, prognosis and incidence of adverse events.
RESULTS In the direct thrombectomy group, the time from admission to imaging examination was 24.32 ± 8.61 min, from admission to arterial puncture was 95.56 ± 37.55 min, from arterial puncture to vascular recanalization was 54.29 ± 21.38 min, and from admission to revascularization was 156.88 ± 45.51 min, and the corresponding times in the bridging treatment group were 25.38 ± 9.33 min, 100.45 ± 39.30 min, 58.14 ± 25.56 min, and 161.23 ± 51.15 min; there were no significant differences between groups (P=0.564, 0.535, 0.426, and 0.661, respectively). There was no significant difference in the recanalization rate between the direct thrombectomy group (79.17%) and the bridging group (75.00%) (P = 0.627). There were no significant differences between the direct thrombectomy group (16.69 ± 4.91 and 12.12 ± 2.07) and the bridging group (7.13 ± 1.23 and (14.40 ± 0.59) in preoperative NIHSS score and GCS score (P = 0.200 and 0.203, respectively). After the operation, the NIHSS scores in both groups were lower than those before the operation, and the GCS scores were higher than those before the operation. There was no significant difference in NIHSS and GCS scores between the direct thrombectomy group (6.91 ± 1.10 and 14.19 ± 0.65) and the bridging group (7.13 ± 1.23 and 14.40 ± 0.59) (P = 0.358 and 0.101, respectively). There was no significant difference in the proportion of patients who achieved a good prognosis between the direct thrombectomy group (52.08%) and the bridging group (50.008%) (P = 0.838). There was no significant difference in the incidence of adverse events between the direct thrombectomy group (6.25%) and the bridging group (8.33%) (P = 0.913).
CONCLUSION Bridging therapy and direct mechanical thrombectomy can safely treat cardiogenic cerebral infarction with anterior circulation macrovascular occlusion, achieve good vascular recanalization effects and prognoses, and improve the neurological function of patients.
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Affiliation(s)
- Hong-Ju Ding
- Department of Emergency, Qingdao Jiaozhou Central Hospital, Qingdao 266300, Shandong Province, China
| | - Cong Ma
- Department of Neurology, Qingdao Jiaozhou Central Hospital, Qingdao 266300, Shandong Province, China
| | - Fu-Ping Ye
- Department of Gastrointestinal Surgery, Qingdao Jiaozhou Central Hospital, Qingdao 266300, Shandong Province, China
| | - Ji-Fang Zhang
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
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7
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Shigeta K, Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, Kamiya Y, Okubo S, Hayakawa M, Ishii N, Koguchi Y, Ota T, Takigawa T, Inoue M, Naito H, Hirano T, Kato N, Ueda T, Akaji K, Iguchi Y, Miki K, Tsuruta W, Fujimoto S, Enomoto M, Aoyama J, Nakano T, Kimura K. Intravenous Alteplase is Associated with First Pass Effect in Stent-retriever but not ADAPT Thrombectomy : Post Hoc Analysis of the SKIP Study. Clin Neuroradiol 2021; 32:153-162. [PMID: 34498093 DOI: 10.1007/s00062-021-01085-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the effect of alteplase, either combined with stent-retriever thrombectomy or a direct aspiration first pass technique (ADAPT), in patients with large-vessel occlusion stroke. METHODS This was a retrospective post hoc analysis of data from The Direct Mechanical Thrombectomy in Acute LVO Stroke (SKIP) study. Patients were divided into two groups according to the first-line thrombectomy technique: stent-retriever and ADAPT. Each group was further divided into two subgroups, namely MT and MT + alteplase. The procedural outcomes, such as first pass effect (FPE) ratio and number of passes, were evaluated. The clinical outcomes included mRS score at 3 months. RESULTS A total of 180 patients were included (116 in the stent-retriever group and 64 in the ADAPT group). No interaction was detected between the first-line technique and alteplase administration. In the stent-retriever group, after adjusting for factors associated with FPE, the adjusted odds ratio (95% confidence interval) of FPE of the MT + alteplase subgroup versus the MT subgroup was 3.57 (1.5-8.48) and in the ADAPT group it was 1.35 (0.37-4.91). With alteplase, the number of passes decreased with adjusted odds ratios of 0.59 (0.37-0.93) in the stent-retriever group but not in the ADAPT group. In both first-line technique groups, clinical outcomes did not differ between subgroups. CONCLUSION In the SKIP study, alteplase administration was associated with increased FPE when combined with stent-retriever thrombectomy, but not with ADAPT. We found no differences in the clinical outcomes.
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Affiliation(s)
- Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan.
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School Hospital, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | | | - Yohei Takayama
- Department of Neurology, Akiyama Neurosurgical Hospital, Kanagawa, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Norihiro Ishii
- Department of Neurosurgery, New Tokyo Hospital, Chiba, Japan
| | - Yorio Koguchi
- Department of Neurology and Neurosurgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Masato Inoue
- Department of Neurosurgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiromichi Naito
- Department of Neurosurgery, Funabashi Municipal Medical Center, Chiba, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Ibaraki, Japan
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kanagawa, Japan
| | - Kazunori Akaji
- Department of Neurosurgery, Mihara Memorial Hospital, Gunma, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, the Jikei University School of Medicine, Tokyo, Japan
| | - Kazunori Miki
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Masaya Enomoto
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Jiro Aoyama
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Tomoyuki Nakano
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Hospital, Tokyo, Japan
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8
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Regenhardt RW, Rosenthal JA, Awad A, Martinez-Gutierrez JC, Nolan NM, McIntyre JA, Whitney C, Alotaibi NM, Dmytriw AA, Vranic JE, Stapleton CJ, Patel AB, Rost NS, Schwamm LH, Leslie-Mazwi TM. 'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model. J Neurointerv Surg 2021; 14:650-653. [PMID: 34326197 DOI: 10.1136/neurintsurg-2021-017819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/11/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Randomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., 'drip-and-ship' model) versus those not. METHODS Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b-3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence. RESULTS Among 258 patients, median age was 70 years (IQR 60-81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b-3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06). CONCLUSIONS Intravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.
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Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA .,Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph A Rosenthal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amine Awad
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Neal M Nolan
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joyce A McIntyre
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cynthia Whitney
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Naif M Alotaibi
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neuroradiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher J Stapleton
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia S Rost
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Chen ZJ, Li XF, Liang CY, Cui L, Yang LQ, Xia YM, Cao W, Gao BL. Comparison of Prior Bridging Intravenous Thrombolysis With Direct Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion: Systematic Review and Meta-Analysis. Front Neurol 2021; 12:602370. [PMID: 33995238 PMCID: PMC8120007 DOI: 10.3389/fneur.2021.602370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/15/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Whether bridging treatment combining intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) is superior to direct EVT alone for emergent large vessel occlusion (LVO) in the anterior circulation is unknown. A systematic review and a meta-analysis were performed to investigate and assess the effect and safety of bridging treatment vs. direct EVT in patients with LVO in the anterior circulation. Methods: PubMed, EMBASE, and the Cochrane library were searched to assess the effect and safety of bridging treatment and direct EVT in LVO. Functional independence, mortality, asymptomatic and symptomatic intracranial hemorrhage (aICH and sICH, respectively), and successful recanalization were evaluated. The risk ratio and the 95% CI were analyzed. Results: Among the eight studies included, there was no significant difference in the long-term functional independence (OR = 1.008, 95% CI = 0.845–1.204, P = 0.926), mortality (OR = 1.060, 95% CI = 0.840–1.336, P = 0.624), recanalization rate (OR = 1.015, 95% CI = 0.793–1.300, P = 0.905), and the incidence of sICH (OR = 1.320, 95% CI = 0.931–1.870, P = 0.119) between bridging therapy and direct EVT. After adjusting for confounding factors, bridging therapy showed a lower recanalization rate (effect size or ES = −0.377, 95% CI = −0.684 to −0.070, P = 0.016), but there was no significant difference in the long-term functional independence (ES = 0.057, 95% CI = −0.177 to 0.291, P = 0.634), mortality (ES = 0.693, 95% CI = −0.133 to 1.519, P = 0.100), and incidence of sICH (ES = −0.051, 95% CI = −0.687 to 0.585, P = 0.875) compared with direct EVT. Meanwhile, in the subgroup analysis of RCT, no significant difference was found in the long-term functional independence (OR = 0.927, 95% CI = 0.727–1.182, P = 0.539), recanalization rate (OR = 1.331, 95% CI = 0.948–1.867, P = 0.099), mortality (OR = 1.072, 95% CI = 0.776–1.481, P = 0.673), and sICH incidence (OR = 1.383, 95% CI = 0.806–2.374, P = 0.977) between patients receiving bridging therapy and those receiving direct DVT. Conclusion: For stroke patients with acute anterior circulation occlusion and who are eligible for intravenous thrombolysis, there is no significant difference in the clinical effect between direct EVT and bridging therapy, which needs to be verified by more randomized controlled trials.
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Affiliation(s)
- Zhao-Ji Chen
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Xiao-Fang Li
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Cheng-Yu Liang
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Lei Cui
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Li-Qing Yang
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Yan-Min Xia
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Wei Cao
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Bu-Lang Gao
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
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10
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Alzayiani M, Schmidt T, Veldeman M, Riabikin A, Brockmann MA, Schiefer J, Clusmann H, Schubert GA, Albanna W. Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment. J Neurol Sci 2020; 420:117275. [PMID: 33352507 DOI: 10.1016/j.jns.2020.117275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Revascularization by pharmacological and/or endovascular treatment is an effective therapy for acute ischemic stroke caused by artery occlusion. In the context of malignant middle cerebral artery infarction (MMI), decompressive hemicraniectomy (DHC) can be life-saving. However, its effectiveness and safety after revascularization have not been thoroughly assessed. This retrospective study aimed to determine the risk profile of pre-surgical revascularization treatment (RT) for subsequent DHC. METHODS A total of 152 consecutive patients treated by DHC after MMI were identified between 2012 and 2015. After elimination of cases with previous stroke and cases pre-treated with antiplatelets or anticoagulants (increased postoperative bleeding), twenty-four out of fifty patients (n = 24/50, 48%) received pre-surgical revascularization treatment by intravenous thrombolysis (TL), mechanical thrombectomy (MT) or a combination of both. Demographic data was compared alongside perioperative, postoperative complications (intra-/extracerebral hemorrhage, revision surgery due to hemorrhage or infection, and overall mortality) and economic parameters. RESULTS Comparing patients with and without prior RT, there was no statistically significant difference in duration of surgery (RT: 83 [57-116] min vs. no-RT: 96 [69-119] min, p = 0.308), intraoperative blood loss (RT: 300 [225-375] ml vs. no-RT: 300 [250-400] ml, p = 0.763), intraoperative transfusion requirement (RT: 12.5% vs. no-RT: 26.9%, p = 0.294), or need for volume substitution (RT: 1300 [1200-1400] ml vs. no-RT: 1200 [1100-1400] ml, p = 0.359). The rate of postoperative complications was also comparable in both groups, including intra-/extracerebral hemorrhage, revision due to hemorrhage or infections, and mortality (p = 0.814, p = 0.520, p = 0.697, and p = 0.769). Health economic parameters were not affected (ventilation time: RT: 309 [12-527] hrs. vs. no-RT: 444 [171-605] hrs., p = 0.120, length of stay: RT: 23 [13-32] days vs. no-RT: 28 [19-41], p = 0.156, and stay costs: RT: 27768 [13044-60,248] € vs. no-RT: 35422 [21225-49,585] €, p = 0.312). CONCLUSION DHC for patients with MMI who previously received revascularization therapy appears to be safe and not associated with a higher complication rate or increased health economic burden.
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Affiliation(s)
| | - Tobias Schmidt
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Alexander Riabikin
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Marc A Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany; Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
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11
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Siegler JE, Jovin TG. Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Dynamic Hyperglycemic Patterns Predict Adverse Outcomes in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy. J Clin Med 2020; 9:jcm9061932. [PMID: 32575739 PMCID: PMC7355777 DOI: 10.3390/jcm9061932] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Admission hyperglycemia impairs outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). Since hyperglycemia in AIS represents a dynamic condition, we tested whether the dynamic patterns of hyperglycemia, defined as blood glucose levels > 140 mg/dl, affect outcomes in these patients. METHODS We retrospectively analyzed data of 200 consecutive patients with prospective follow-up. Based on blood glucose level, patients were distinguished into 4 groups: (1) persistent normoglycemia; (2) hyperglycemia at baseline only; (3) hyperglycemia at 24-h only; and (4) persistent (at baseline plus at 24-h following MT) hyperglycemia. RESULTS AIS patients with persistent hyperglycemia have a significantly increased risk of poor functional outcome (OR 6.89, 95% CI 1.98-23.94, p = 0.002, for three-month poor outcome; OR 11.15, 95% CI 2.99-41.52, p = 0.001, for no major neurological improvement), mortality (OR 5.37, 95% CI 1.61-17.96, p = 0.006, for in-hospital mortality; OR 4.43, 95% CI 1.40-13.97, p = 0.01, for three-month mortality), and hemorrhagic transformation (OR 6.89, 95% CI 2.35-20.21, p = 0.001, for intracranial hemorrhage; OR 5.42, 95% CI 1.54-19.15, p = 0.009, for symptomatic intracranial hemorrhage) after endovascular treatment. These detrimental effects were partially confirmed after also excluding diabetic patients. The AUC-ROC showed a very good performance for predicting three-month poor outcome (0.76) in-hospital mortality (0.79) and three-month mortality (0.79). CONCLUSIONS Our study suggests that it is useful to perform the prolonged monitoring of glucose levels lasting 24-h after MT.
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13
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Smaal JA, de Ridder IR, Heshmatollah A, van Zwam WH, Dippel D, Majoie CB, Brown S, Goyal M, Campbell B, Muir KW, Demchuck AM, Davalos A, Jovin TG, Mitchell PJ, White P, Saver JL, Hill MD, Roos YB, van der Lugt A, van Oostenbrugge RJ. Effect of atrial fibrillation on endovascular thrombectomy for acute ischemic stroke. A meta-analysis of individual patient data from six randomised trials: Results from the HERMES collaboration. Eur Stroke J 2020; 5:245-251. [PMID: 33072878 PMCID: PMC7538768 DOI: 10.1177/2396987320923447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background Atrial fibrillation is an important risk factor for ischemic stroke, and is
associated with an increased risk of poor outcome after ischemic stroke.
Endovascular thrombectomy is safe and effective in acute ischemic stroke
patients with large vessel occlusion of the anterior circulation. This
meta-analysis aims to investigate whether there is an interaction between
atrial fibrillation and treatment effect of endovascular thrombectomy, and
secondarily whether atrial fibrillation is associated with worse outcome in
patients with ischemic stroke due to large vessel occlusion. Methods Individual patient data were from six of the recent randomised clinical
trials (MR CLEAN, EXTEND-IA, REVASCAT, SWIFT PRIME, ESCAPE, PISTE) in which
endovascular thrombectomy plus standard care was compared to standard care
alone. Primary outcome measure was the shift on the modified Rankin scale
(mRS) at 90 days. Secondary outcomes were functional independence (mRS 0–2)
at 90 days, National Institutes of Health Stroke Scale score at 24 h,
symptomatic intracranial hemorrhage and mortality at 90 days. The primary
effect parameter was the adjusted common odds ratio, estimated with ordinal
logistic regression (shift analysis); treatment effect modification of
atrial fibrillation was assessed with a multiplicative interaction term. Results Among 1351 patients, 447 patients had atrial fibrillation, 224 of whom were
treated with endovascular thrombectomy. We found no interaction of atrial
fibrillation with treatment effect of endovascular thrombectomy for both
primary (p-value for interaction: 0.58) and secondary
outcomes. Regardless of treatment allocation, we found no difference in
primary outcome (mRS at 90 days: aOR 1.11 (95% CI 0.89–1.38) and secondary
outcomes between patients with and without atrial fibrillation. Conclusion We found no interaction of atrial fibrillation on treatment effect of
endovascular thrombectomy, and no difference in outcome between large vessel
occlusion stroke patients with and without atrial fibrillation.
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Affiliation(s)
- J A Smaal
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - I R de Ridder
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - A Heshmatollah
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W H van Zwam
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Dwj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - C B Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - S Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - M Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Bcv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - K W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - A M Demchuck
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - A Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Spain
| | - T G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - P J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - P White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - J L Saver
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Y B Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - A van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J van Oostenbrugge
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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14
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Yi HJ, Sung JH, Lee DH. Bridging Intravenous Thrombolysis Before Mechanical Thrombectomy for Large Artery Occlusion May be Detrimental with Thrombus Fragmentation. Curr Neurovasc Res 2020; 17:18-26. [DOI: 10.2174/1567202617666191223143831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 11/22/2022]
Abstract
Objective:
We investigated whether intravenous thrombolysis (IVT) affected the outcomes
and complications of mechanical thrombectomy (MT), specifically focusing on thrombus
fragmentation.
Methods:
The patients who underwent MT for large artery occlusion (LAO) were classified into
two groups: MT with prior IVT (MT+IVT) group and MT without prior IVT (MT-IVT) group.
The clinical outcome, successful recanalization with other radiological outcomes, and complications
were compared, between two groups. Subgroup analysis was also performed for patients with
simultaneous application of stent retriever and aspiration.
Results:
There were no significant differences in clinical outcome and successful recanalization
rate, between both groups. However, the ratio of pre- to peri-procedural thrombus fragmentation
was significantly higher in the MT+IVT group (14.6% and 16.2%, respectively; P=0.004) compared
to the MT-IVT group (5.1% and 6.8%, respectively; P=0.008). The MT+IVT group required
more second stent retriever (16.2%), more stent passages (median value = 2), and more occurrence
of distal emboli (3.9%) than the MT-IVT group (7.9%, median value = 1, and 8.1%, respectively)
(P=0.004, 0.008 and 0.018, respectively). In subgroup analysis, the results were similar to those of
the entire patients.
Conclusion:
Thrombus fragmentation of IVT with t-PA before MT resulted in an increased need
for additional rescue therapies, and it could induce more distal emboli. The use of IVT prior to MT
does not affect the clinical outcome and successful recanalization, compared with MT without
prior IVT. Therefore, we need to reconsider the need for IVT before MT.
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Affiliation(s)
- Ho Jun Yi
- Department of Neurosurgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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15
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Fan L, Zang L, Liu X, Wang J, Qiu J, Wang Y. Outcomes of mechanical thrombectomy with pre-intravenous thrombolysis: a systematic review and meta-analysis. J Neurol 2020; 268:2420-2428. [PMID: 32140863 DOI: 10.1007/s00415-020-09778-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Whether pre-intravenous thrombolysis (IVT) provides any extra benefits to mechanical thrombectomy (MT) remains controversial. We conducted a systematic review and meta-analysis to compare MT with pre-IVT (IVT + MT) and MT without pre-IVT (MT) for acute ischemic stroke of large vessel occlusion. METHODS We systematically searched PubMed, EMBASE and Cochrane Library to identify studies comparing outcomes between IVT + MT and MT from inception to Jan 24, 2019. Random effects mode was used to pool relative risk (RR) with confidence intervals (CI) to compare functional independence in terms of modified Rankin Scale (mRS) 0-2, favorable outcome (mRS 0-1) and mortality at three-months, symptomatic intracerebral hemorrhage, successful reperfusion, and complete reperfusion between the two treatments groups. RESULTS We included 30 studies enrolling 8970 patients with acute ischemic stroke of large vessel occlusion. Compared with MT, IVT + MT significantly increased the rate of 3-month functional independence (RR 1.20, 95% CI 1.12-1.30; P < 0.0001) and favorable outcome (RR 1.28; 95% CI 1.16-1.40; P < 0.0001), increased the rate of successful reperfusion (RR 1.04,95% CI 1.01-1.08; P = 0.013) and complete reperfusion (RR 1.10; 95% CI 1.01-1.19; P = 0.024), reduced the rate of mortality (RR 0.74, 95% CI 0.67-0.82; P < 0.0001), without significantly increasing the rate of symptomatic intracerebral hemorrhage (RR 0.98,95% CI 0.82-1.17; P = 0.833). The results remained stable in sensitivity analyses and adjusting for publication bias. CONCLUSIONS Pre-IVT provides extra benefits to MT on clinical and imaging outcomes without increasing symptomatic intracerebral hemorrhage in acute ischemic stroke of large vessel occlusion.
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Affiliation(s)
- Lu Fan
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Dalian Medical University, 9 Western Sections, Lvshun South Street, Dalian, 116044, Lvshunkou District, People's Republic of China
| | - Lin Zang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Dalian Medical University, 9 Western Sections, Lvshun South Street, Dalian, 116044, Lvshunkou District, People's Republic of China
| | - Xiaodong Liu
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Dalian Medical University, 9 Western Sections, Lvshun South Street, Dalian, 116044, Lvshunkou District, People's Republic of China
| | - Jian Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Neurosurgery Department, The First Hospital of China Medical University, 155 Nanjing North Road, Shenyang, 110001, Heping District, People's Republic of China
| | - Jianting Qiu
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China
| | - Yujie Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.
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16
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Chang YJ, Liu CK, Wu WP, Wang SC, Chen WL, Lin CM. The prediction of acute ischemic stroke patients' long-term functional outcomes treated with bridging therapy. BMC Neurol 2020; 20:22. [PMID: 31948412 PMCID: PMC6966893 DOI: 10.1186/s12883-020-1610-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background Intravenous thrombolysis therapy (IVT) bridged with intra-arterial thrombectomy (IAT) has recently been recommended as favorable treatment option to ensure that the thrombolytic effect is delivered to the affected region for acute ischemic stroke patients. However, there remains a lack of studies reporting outcome prediction in this group of patients. In this study, we aimed to identify indicators from baseline data that could be used for early prediction of long-term functional outcomes. Methods This retrospective single center cohort study included acute ischemic stroke (AIS) patients (n = 92) who received IVT and IAT. Functional outcomes were assessed by the National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index. We investigated the relationship between functional outcomes at one-year post-procedure and potential predictors such as occlusion site, modified thrombolysis in cerebral infarction (mTICI) score following the IVT/IAT procedure, and degree of stenosis measured by carotid duplex. Results 67.4% of the studied patients had satisfactory outcomes with mTICI grades of 2b or 3. From baseline to one-year post-procedure, the NIHSS score improved in 88.0%, the mRS score improved in 69.6%, and the Barthel index improved with 59.8%. Patients with internal carotid artery (ICA) or vertebral artery (VA) stenosis detected by carotid duplex had significantly poorer functional outcomes, measured by the mRS score and Barthel index. In patients with a satisfactory mTICI grade, improvement in the mRS score was only observed in 60.0% of patients with ICA stenosis, compared to 93.8% without ICA stenosis. The VA stenosis was the most significant factor associated with the improvement of mRS (OR = 0.08; 95% CI: 0.01–0.63; P = 0.017) and Barthel Index (OR = 0.06; 95% CI: 0.01–0.47; P = 0.008) in multiple regression analysis. Conclusions ICA or VA stenosis detected by carotid duplex could serve as predictors of significantly poorer functional outcomes in stroke patients treated with bridging therapy; they might be useful clinical markers, particularly as stenosis could be detected by a non-invasive and portable method.
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Affiliation(s)
- Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi-Kuang Liu
- Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Pei Wu
- Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Chun Wang
- Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Liang Chen
- Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan.
| | - Chih-Ming Lin
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan. .,Department of Social Work and Child Welfare, Providence University, Taichung, Taiwan. .,Department of Medicinal Botanicals and Health Applications, Da-Yeh University, Changhua County, Taiwan.
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17
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Imbarrato G, Bentley J, Gordhan A. Clinical Outcomes of Endovascular Thrombectomy in Tissue Plasminogen Activator versus Non-Tissue Plasminogen Activator Patients at Primary Stroke Care Centers. J Neurosci Rural Pract 2019; 9:240-244. [PMID: 29725176 PMCID: PMC5912031 DOI: 10.4103/jnrp.jnrp_497_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: The effect of intravenous tissue plasminogen activator (IV tPA) administration before endovascular intervention as compared to without at thrombectomy-capable low-volume centers on procedural aspects and patient outcomes has not been investigated. Methods: Retrospective chart review was performed in all consecutive large vessel cerebrovascular accident patients treated with endovascular therapy at two select rural primary stroke centers between 2011 and 2015. Patients’ data regarding age, sex, and medical history, as well as thrombus location by catheter-based cerebral angiography, postprocedural reperfusion status, and clinical outcomes were reviewed. The primary outcome measure of the study was a comparison of modified Rankin scale (MRS) at 90 days in patients’ postendovascular thrombectomy with prior IV tPA administration versus those who underwent thrombectomy and did not qualify for preprocedural IV tPA. Results: After application of the set inclusion and exclusion criteria, data of 46 out of 65 patients were analyzed. Twenty-three patients (50%) received IV tPA before thrombectomy and 23 patients did not qualify for IV tPA (50%). Successful recanalization (thrombolysis in cerebral infarction 2b/3) was achieved in 86% (20/23 patients) of thrombectomy patients without preprocedural IV tPA and 82% (19/23) of patients who received it (odds ratio [OR]: 0.03, confidence interval [CI]: 95% 0.062–0.16, P < 0.0001). MRS of 2 or less at 90 days was 43.4% (10/23) in patients with no preprocedural IV tPA and 39.1% (9/23) in the combined therapy group (OR: 0.84, CI: 0.26–2.70, P = 0.8). Conclusion: Patients undergoing endovascular thrombectomy for large vessel occlusion at select low-volume rural centers showed benefit from this treatment regardless of IV tPA administration. Clinical outcomes and complications at select low-volume thrombectomy-proficient centers are comparable to large volume comprehensive stroke centers as well as the landmark studies proving the efficacy of endovascular treatment.
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Affiliation(s)
- Gregory Imbarrato
- Department of Graduate Medical Education, Advocate Bromenn Neurological Surgery Residency Program, Normal, IL, USA
| | - Joshua Bentley
- Swedish Medical Center, Swedish Neuroscience Institute, Cherry Hill, Seattle, WA, USA
| | - Ajeet Gordhan
- Department of Neurosciences, Advocate Bromenn Hospital, Normal, IL, USA.,St. Joseph Medical Center, Bloomington, IL, USA
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18
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Is intravenous thrombolysis still necessary in patients who undergo mechanical thrombectomy? Curr Opin Neurol 2019; 32:3-12. [PMID: 30461464 DOI: 10.1097/wco.0000000000000633] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To summarize available evidence on the potential utility of pretreatment with intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO) who are treated with mechanical thrombectomy. RECENT FINDINGS Despite theoretical concerns of a higher bleeding risk with IVT pretreatment, there are no data showing increased risk of symptomatic intracerebral hemorrhage (sICH) in patients with LVO receiving bridging therapy (IVT and mechanical thrombectomy) compared with direct mechanical thrombectomy (dMT). Additionally, evidence from observational studies suggest lower rates of infarctions in previously unaffected territories and higher rates of successful reperfusion, with lower number of device passes, in patients receiving bridging therapy. There are substantial discrepancies in studies comparing clinical outcomes between dMT and bridging therapy that are directly related to the inclusion of patients with contraindications to IVT in the dMT group. Ongoing clinical trials will provide definitive answers on the potential additional benefit of IVT in LVO patients receiving mechanical thrombectomy. SUMMARY IVT and mechanical thrombectomy are two effective reperfusion therapies that should be used in a swift and noncompeting fashion in AIS patients. AIS patients with LVO and no contraindications for IVT should receive promptly rt-PA bolus followed by immediate initiation of mechanical thrombectomy as indicated by current international recommendations, unless future randomized controlled trials provide evidence to proceed differently.
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Nicastro N, Eger AF, Boukrid II, Mueller HFG, Machi P, Vargas MI, Poletti PA, Platon A, Sztajzel RF. Earlier IV thrombolysis and mechanical thrombectomy in acute ischemic stroke are associated with a better recanalization. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x19855602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Combined intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the recommended treatment options for acute ischemic stroke (AIS). It is unclear whether earlier IVT and MT management can predict complete vessel recanalization. Methods: In this single-center retrospective observational study, we included 81 consecutive subjects with proximal middle cerebral artery AIS (age 70.5 ± 14.2 years, 53% female) who had both IVT and MT. We assessed recanalization after mechanical procedure according to modified thrombolysis in cerebral infarction (TICI) score as well as the National Institute of Health Stroke Scale (NIHSS) score at 24 h. Outcomes were modified Rankin Scale (mRS) at discharge, mRS at 3 months, death at 3 months, and prevalence of intracerebral hemorrhage during hospitalization. Results: Multinomial logistic regression ( χ 2 = 49.4, p = 0.0075, pseudo- R 2 = 0.26) showed that complete recanalization (TICI score = 3) was predicted by lower door-to-MT time ( p = 0.014, 95% confidence interval (CI) = −0.09 to −0.01) and lower symptoms-to-IVT time ( p = 0.045, 95% CI = −0.038 to −0.0004). An NIHSS score ≥10 at 24 h was predicted by higher baseline NIHSS ( p < 0.0001) and lower TICI score ( p = 0.009). Lower NIHSS at 24 h predicted a good outcome according to mRS at 3 months ( p = 0.006). Similarly, higher NIHSS at 24 h was a predictor of death at 3 months ( p = 0.013). Conclusions: The present study suggests that bridging therapy may improve vascular recanalization when both IVT and MT are performed earlier.
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Affiliation(s)
- Nicolas Nicastro
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Division of Neurorehabilitation, Geneva University Hospitals, Geneva, Switzerland
| | - Antoine F Eger
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Iman I Boukrid
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Paolo Machi
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Alexandra Platon
- Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
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Gamba M, Gilberti N, Premi E, Costa A, Frigerio M, Mardighian D, Vergani V, Spezi R, Delrio I, Morotti A, Poli L, De Giuli V, Caria F, Pezzini A, Gasparotti R, Padovani A, Magoni M. Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results. BMC Neurol 2019; 19:103. [PMID: 31142273 PMCID: PMC6540520 DOI: 10.1186/s12883-019-1341-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023] Open
Abstract
Background endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients remains unclear. The present study aims to investigate whether IVT followed by ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS with LVO. Methods we achieved a single center retrospective study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. Functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up brain CT scan infarct volume (EFIV) (for recanalized patients only), symptomatic intracerebral hemorrhage (sICH) and 3-month mortality were the outcomes of interests. Independent predictors of the outcomes were explored with multivariable logistic regression. Results 145 subjects were included in the study, of whom 70 underwent direct ET and 75 were treated with CoT. Functional independence at 3-months was more frequent in CoT subjects compared to patients who received direct ET (mRS score 0–1: 48.5% vs 18.6%; P < 0.001. mRS score 0–2: 67.1% vs 37.3%; P < 0.001); CoT patients had also higher first-pass success rate (62.7% vs 38.6%, P < 0.05), higher recanalization rate (84.3% vs 65.3%; P = 0.009) and, in recanalized subjects, smaller EFIV (16.4 ml vs 62.3 ml; P = 0.003). Mortality and intracranial bleeding did not differ between the two groups. In multivariable regression analysis, low baseline NIHSS score (P < 0.05), vessel recanalization (P = 0.05) and CoT (P = 0.03) were independent predictors of favorable outcome at three months. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.
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Affiliation(s)
- Massimo Gamba
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy.
| | - Nicola Gilberti
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Enrico Premi
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Angelo Costa
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Michele Frigerio
- Servizio di Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Dikran Mardighian
- Servizio di Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Veronica Vergani
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Raffaella Spezi
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Ilenia Delrio
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Andrea Morotti
- Stroke Unit, IRCCS Fondazione Istituto Neurologico Nazionale "C. Mondino", Pavia, Italy
| | - Loris Poli
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Valeria De Giuli
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Filomena Caria
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Alessandro Pezzini
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Roberto Gasparotti
- Servizio di Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Alessandro Padovani
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Mauro Magoni
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
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Chalos V, LeCouffe NE, Uyttenboogaart M, Lingsma HF, Mulder MJHL, Venema E, Treurniet KM, Eshghi O, van der Worp HB, van der Lugt A, Roos YBWEM, Majoie CBLM, Dippel DWJ, Roozenbeek B, Coutinho JM. Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke. J Am Heart Assoc 2019; 8:e011592. [PMID: 31140355 PMCID: PMC6585366 DOI: 10.1161/jaha.118.011592] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background It is unclear whether intravenous thrombolysis ( IVT ) with alteplase before endovascular treatment ( EVT ) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results Using multivariable regression, we evaluated the association of IVT + EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT + EVT , and 324 (22%) with EVT alone. Patients treated with IVT + EVT had atrial fibrillation less often (16% versus 44%) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT + EVT group (median 62 versus 68 minutes). Nontransferred IVT + EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT + EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI : 1.10-1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI : 0.40-0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions In this observational study, patients treated with IVT + EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT , but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT .
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Affiliation(s)
- Vicky Chalos
- 1 Department of Neurology Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands.,2 Public Health Center for Medical Decision Making Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands.,3 Radiology and Nuclear Medicine Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Natalie E LeCouffe
- 4 Department of Neurology Amsterdam UMC University of Amsterdam The Netherlands.,5 Radiology and Nuclear Medicine Amsterdam UMC University of Amsterdam The Netherlands
| | - Maarten Uyttenboogaart
- 6 Department of Neurology University Medical Center Groningen Groningen The Netherlands.,7 Radiology University Medical Center Groningen Groningen The Netherlands
| | - Hester F Lingsma
- 2 Public Health Center for Medical Decision Making Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Maxim J H L Mulder
- 1 Department of Neurology Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Esmee Venema
- 2 Public Health Center for Medical Decision Making Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Kilian M Treurniet
- 5 Radiology and Nuclear Medicine Amsterdam UMC University of Amsterdam The Netherlands
| | - Omid Eshghi
- 7 Radiology University Medical Center Groningen Groningen The Netherlands
| | - H Bart van der Worp
- 8 Department of Neurology and Neurosurgery Brain Center Rudolf Magnus University Medical Center Utrecht Utrecht The Netherlands
| | - Aad van der Lugt
- 3 Radiology and Nuclear Medicine Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Yvo B W E M Roos
- 4 Department of Neurology Amsterdam UMC University of Amsterdam The Netherlands
| | - Charles B L M Majoie
- 5 Radiology and Nuclear Medicine Amsterdam UMC University of Amsterdam The Netherlands
| | - Diederik W J Dippel
- 1 Department of Neurology Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Bob Roozenbeek
- 1 Department of Neurology Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands.,3 Radiology and Nuclear Medicine Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Jonathan M Coutinho
- 4 Department of Neurology Amsterdam UMC University of Amsterdam The Netherlands
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Effectiveness of Low-Dose Intravenous Tissue Plasminogen Activator before Stent Retriever or Aspiration Mechanical Thrombectomy. J Vasc Interv Radiol 2019; 30:134-140. [PMID: 30717945 DOI: 10.1016/j.jvir.2018.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine whether thrombolysis with a lower dose of intravenous recombinant tissue plasminogen activator before mechanical thrombectomy is beneficial for functional outcomes compared with mechanical thrombectomy alone. MATERIALS AND METHODS Data for 100 Japanese patients who underwent mechanical thrombectomy between July 2014 and November 2017 were retrospectively reviewed. These patients were divided into groups according to whether they received intravenous thrombolysis before mechanical thrombectomy, and outcomes were compared. Favorable outcome was defined as a modified Rankin scale score ≤ 2 at 3 months after treatment. RESULTS Thirty-four patients for the thrombolysis group and 66 patients for the thrombectomy-only group were identified. The thrombolysis and nonthrombolysis groups did not differ significantly in baseline characteristics (mean age, 74.3 y vs 75.7 y [P = .485]; mean preoperative National Institute Health Stroke Scale score, 19.8 vs 19.6 [P = .825]). There were no significant differences in the times required for, or the rates of, successful recanalization. However, the thrombolysis group had a higher rate of complete recanalization (67.6% vs 43.9%; P = .041). Postoperative symptomatic intracranial hemorrhage was not significantly different between groups. Favorable outcomes were observed in 73.5% of patients in the thrombolysis group and 51.5% in the nonthrombolysis group (P = .028). CONCLUSIONS This single-center retrospective study shows that lower-dose intravenous thrombolysis improves the outcomes of mechanical thrombectomy for Japanese patients with acute anterior-circulation stroke treated within 4.5 hours of onset.
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Pan X, Liu G, Wu B, Liu X, Fang Y. Comparative efficacy and safety of bridging strategies with direct mechanical thrombectomy in large vessel occlusion: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14956. [PMID: 30946319 PMCID: PMC6456029 DOI: 10.1097/md.0000000000014956] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Whether bridging strategies[intravenous thrombolysis (IVT) + mechanical thrombectomy (MT)] are superior to mechanical thrombectomy alone for large vessel occlusion(LVO) is still uncertain. A systematic review and meta-analysis was conducted to investigate and evaluate comparative efficacy and safety of bridging strategies vs direct MT in patients with LVO. METHODS The PubMed, EMBASE and Cochrane library databases were searched to evaluate the efficacy and safety of bridging strategies with direct MT in LVO. Functional independence, mortality, symptomatic intracranial hemorrhage (sICH) and successful recanalization were assessed. The risk ratio (RR) and its 95% confidence interval (CI) were calculated. RESULTS The proportion of patients who received MT + IVT was significantly higher in functional independence and successful recanalization rate than MT alone patients. However, pooled results showed that the mortality of patients who received MT + IVT was significantly lower than that of MT alone patients. Moreover, no significant differences were observed in the incidence of sICH between the 2 groups. CONCLUSION The findings of our meta-analysis confirmed that bridging strategies improved functional outcomes, successful recanalization rate and reduced mortality rates. Moreover, the incidence of sICH showed no differences between the bridging strategies and MT alone treatments. However, the conduct of high-quality randomized clinical trials that directly compare both strategies is warranted.
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Affiliation(s)
- Xiaohua Pan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Guorong Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Xiuzhen Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Yong Fang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
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Ferrigno M, Bricout N, Leys D, Estrade L, Cordonnier C, Personnic T, Kyheng M, Henon H. Intravenous Recombinant Tissue-Type Plasminogen Activator: Influence on Outcome in Anterior Circulation Ischemic Stroke Treated by Mechanical Thrombectomy. Stroke 2018; 49:1377-1385. [PMID: 29748424 DOI: 10.1161/strokeaha.118.020490] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/24/2018] [Accepted: 04/17/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) improves functional outcome in patients with ischemic stroke related to proximal-vessel occlusion in the anterior circulation. Whether MT alone is as effective as IVT/MT remains controversial. We aimed at evaluating the influence of IVT in patients with large anterior circulation artery occlusion treated with MT. METHODS We did a prospective observational cohort study in patients with stroke related to large anterior circulation artery occlusion treated by MT who were admitted to Lille University Hospital, Lille, France. We evaluated the influence of IVT on favorable functional outcome (defined as a modified Rankin Scale score 0-2 or similar to the prestroke modified Rankin Scale) and on mortality at month 3. Between-group comparisons in outcomes were adjusted for prespecified confoundors by using a propensity score-adjusted approach. RESULTS From January 2012 to January 2017, we included 485 patients (median age, 68 years; 46% men; 348 [72%] in the IVT/MT group; 137 [28%] in the MT group). In MT group, 22% of patients had a favorable outcome versus 35% in IVT/MT group (adjusted relative risk, 1.76; 95% confidence interval, 1.23-2.55). Mortality within 3 months occurred less frequently in IVT/MT group (14% versus 32%; adjusted relative risk, 0.46; 95% confidence interval, 0.31-0.70). Successful reperfusion (Thrombolysis in Cerebral Infarction scale 2b-3) was more frequent in IVT/MT group (75% versus 60%; adjusted relative risk, 1.30; 95% confidence interval, 1.11-1.53). There was no difference between groups on hemorrhagic complications. CONCLUSIONS In this population, previous IVT improved functional outcome and survival at 3 months in patients treated by MT. While waiting for randomized controlled trials, this result encourages not to avoid IVT before MT.
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Affiliation(s)
- Marc Ferrigno
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Didier Leys
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Laurent Estrade
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Charlotte Cordonnier
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Thomas Personnic
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Maeva Kyheng
- Department of Biostatistics, CHRU Lille (M.K.), University of Lille, France
| | - Hilde Henon
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
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Choi JH, Im SH, Lee KJ, Koo JS, Kim BS, Shin YS. Comparison of Outcomes After Mechanical Thrombectomy Alone or Combined with Intravenous Thrombolysis and Mechanical Thrombectomy for Patients with Acute Ischemic Stroke due to Large Vessel Occlusion. World Neurosurg 2018; 114:e165-e172. [PMID: 29510288 DOI: 10.1016/j.wneu.2018.02.126] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) provides additional benefits remains controversial. We aimed to compare clinical and radiologic outcomes between IVT+MT and MT alone groups. METHODS We retrospectively reviewed the clinical and radiological features of patients from the prospectively collected database who sustained anterior circulation stroke due to large vessel occlusion (LVO) and were treated with MT within 8 hours of symptom onset. We compared rates of successful reperfusion, functional independence and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) as clinical endpoints between the 2 groups. RESULTS The 81 patients included in this study included 38 (46.9%) in the MT alone group (mean age, 72.6 ± 14.1 years; 17 males [44.7%]) and 43 in the IVT+MT group (mean age, 68.9 ± 12.8 years; 29 males [67.4%]). There were no significant differences in patient baseline characteristics between the 2 groups except for a male predominance in the IVT+MT group. The mean interval from onset to groin puncture (221.6 ± 110.5 minutes vs. 204.7 ± 63.7 minutes; P = 0.472) and the rate of successful reperfusion rate (thrombolysis in cerebral infarction 2b/3, 60.5% vs. 58.1%; P = 0.827) did not differ significantly between the MT and IVT+MT groups. The rate of favorable functional outcome, as determined by a modified Rankin Scale score 0-2 (36.8% vs. 51.2%; P = 0.263) and mortality at 90 days (18.4% vs. 9.3%; P = 0.332), and the rate of sICH (5.3% vs. 4.6%; P = 1.000) were also not significantly different between the 2 groups. CONCLUSIONS This study suggests that previous IVT might not facilitate successful reperfusion and favorable functional outcomes in patients with anterior circulation stroke treated with MT. MT alone can be a safe and effective treatment modality in patients who are ineligible for IVT for various reasons.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Sang Hyuk Im
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Ki Jeong Lee
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Ja Seong Koo
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Bum Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea.
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