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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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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: 0] [Impact Index Per Article: 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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Yousefian Jazi E, Wiesmann M, Reich A, Gombert A, Pinho J, Kotelis D, Nikoubashman O. Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients. Vasc Endovascular Surg 2022; 56:571-580. [DOI: 10.1177/15385744221095669] [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]
Abstract
Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion ( P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.
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Affiliation(s)
- Ehsan Yousefian Jazi
- Department of Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Alex Gombert
- Department of Vascular Surgery, University Hospital, RWTH Aachen University, Aachen, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
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StrokeWatch: An Instrument for Objective Standardized Real-Time Measurement of Door-to-Needle Times in Acute Ischemic Stroke Treatment. J Stroke Cerebrovasc Dis 2021; 30:105962. [PMID: 34265596 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/12/2021] [Accepted: 06/17/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Monitoring critical time intervals in acute ischemic stroke treatment delivers metrics for quality of performance - the door-to-needle time being well-established. To resolve the conflict of self-reporting bias a "StrokeWatch" was designed - an instrument for objective standardized real-time measurement of procedural times. MATERIALS AND METHODS An observational, monocentric analysis of patients receiving intravenous thrombolysis for acute ischemic stroke between January 2018 and September 2019 was performed based on an ongoing investigator-initiated, prospective, and blinded endpoint registry. Patient data and treatment intervals before and after introduction of "StrokeWatch" were compared. RESULTS "StrokeWatch" was designed as a mobile board equipped with three digital stopwatches tracking door-to-needle, door-to-groin, and door-to-recanalization intervals as well as a form for standardized documentation. 118 patients before introduction of "StrokeWatch" (subgroup A) and 53 patients after introduction of "StrokeWatch" (subgroup B) were compared. There were no significant differences in baseline characteristics, procedural times, or clinical outcome. A non-significant increase in patients with door-to-needle intervals of 60 min or faster (93.2 vs 98.1%, p = 0.243) and good functional outcome (mRS d90 ≤ 2, 47.5 vs 58.5%, p = 0.218) as well as a significant increase in reports of delayed arrival of intra-hospital patient transport service (0.8 vs 13.2%, p = 0.001) were observed in subgroup B. CONCLUSIONS The implementation of StrokeWatch for objective standardized real-time measurement of door-to-needle times is feasible in a real-life setting without negative impact on procedural times or outcome. It helped to reassure a high-quality treatment standard and reveal factors associated with procedural delays.
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5
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Wang Y, Wu X, Zhu C, Mossa-Basha M, Malhotra A. Bridging Thrombolysis Achieved Better Outcomes Than Direct Thrombectomy After Large Vessel Occlusion: An Updated Meta-Analysis. Stroke 2020; 52:356-365. [PMID: 33302795 DOI: 10.1161/strokeaha.120.031477] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The utility and necessity of pretreatment with intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains an issue of strong debate. This study aims to compare the outcomes of bridging thrombolysis (BT, IVT+MT) with direct MT (d-MT) after large vessel ischemic stroke based on the most up-to-date evidence. MEDLINE, EMBASE, Scopus, and the Cochrane Library from January 2017 to June 2020 were searched for studies that directly compared the outcomes of the 2 strategies. Methodological quality was assessed using the Quality in Prognostic Studies tool. Combined estimates of odds ratios (ORs) of BT versus d-MT were derived. Multiple subgroup analyses were performed, especially for IVT-eligible patients. Thirty studies involving 7191 patients in the BT group and 4891 patients in the d-MT group were included. Methodological quality was generally high. Compared with patients in the d-MT group, patients in the BT group showed significantly better functional independence (modified Rankin Scale score 0-2) at 90 days (OR=1.43 [95% CI, 1.28-1.61]), had lower mortality at 90 days (OR=0.67 [95% CI, 0.60-0.75]), and achieved higher successful recanalization (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate (OR=1.23 [95% CI, 1.07-1.42]). No significant difference was detected in the occurrence of symptomatic intracranial hemorrhage between 2 groups (OR=1.01 [95% CI, 0.86-1.19]). Subgroup analysis showed that functional independence frequency remained significantly higher in BT group regardless of IVT eligibility or study design. Compared with d-MT, bridging with IVT led to better clinical outcomes, lower mortality at 90 days, and higher successful recanalization rates, without increasing the risk of near-term hemorrhagic complications. The benefits of BT based on this most recent literature evidence support the current guidelines of using BT.
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Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu (Y.W.)
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California, San Francisco (X.W.)
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine and Yale University, New Haven, CT (A.M.)
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Hinsenveld WH, de Ridder IR, van Oostenbrugge RJ, van Zwam WH, Vos JA, Coutinho JM, Lycklama À Nijeholt GJ, Boiten J, Schonewille WJ. Intravenous Thrombolysis Is Not Associated with Increased Time to Endovascular Treatment. Cerebrovasc Dis 2020; 49:321-327. [PMID: 32615562 DOI: 10.1159/000508898] [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: 03/02/2020] [Accepted: 05/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endovascular treatment (EVT) with or without intravenous thrombolysis (IVT) is effective and safe in is-chemic stroke caused by large vessel occlusion, but IVT might delay time to EVT or increase risk of intracranial hemorrhage (ICH). We assessed the influence of prior IVT on time to treatment and risk of ICH in patients treated with EVT. METHODS We analyzed data from the MR CLEAN Registry and included patients with an anterior circulation occlusion treated with EVT who presented directly to an intervention center, between 2014 and 2017. Primary endpoint was the door to groin time. Secondary outcomes were workflow time intervals and safety outcomes. We compared patients who received EVT only with patients who received IVT prior to EVT. RESULTS We included 1,427 patients directly referred to an intervention center of whom 1,023 (72%) received IVT + EVT. Adjusted door to CT imaging and door to groin time were shorter in IVT + EVT patients (difference 5.7 min [95% CI: 4.6-6.8] and 7.0 min [95% CI: 2.4-12], respectively) while CT imaging to groin time was similar between the groups. Early recanalization on digital subtraction angiography before EVT was seen more often after prior IVT (11 vs. 5.2%, aOR 2.4 [95% CI: 1.4-4.2]). Rates of symptomatic ICH were similar. CONCLUSION Prior IVT did not delay door to groin times and was associated with higher rates of early recanalization, without increasing the risk of ICH. Our results do not warrant withholding IVT prior to EVT.
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Affiliation(s)
- Wouter H Hinsenveld
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands,
| | - Inger R de Ridder
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Albert Vos
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | | | - Jelis Boiten
- Department of Neurology and Radiology, Haaglanden Medical Center, The Hague, The Netherlands
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7
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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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Feda S, Nikoubashman O, Schürmann K, Matz O, Tauber SC, Wiesmann M, Schulz JB, Reich A. Endovascular stroke treatment does not preclude high thrombolysis rates. Eur J Neurol 2018; 26:428-e33. [PMID: 30317687 DOI: 10.1111/ene.13831] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/08/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE In 1995 intravenous recombinant tissue plasminogen activator (IVRTPA) was the first reperfusion therapy to be approved in patients with acute ischaemic stroke (AIS). The significance and impact of IVRTPA in times of modern endovascular stroke treatment (EST) were analysed in a German academic stroke centre. METHODS A retrospective observational cohort analysis of 1034 patients with suspected AIS presenting at the emergency department in 2014 was performed. Patients were evaluated for baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcome, symptomatic intracranial haemorrhage (sICH) and mortality. Data acquisition was part of an investigator-initiated, prospective and blinded end-point registry. RESULTS In 718 (69%) patients the diagnosis of symptomatic AIS was confirmed. 419 (58%) patients presented within 4.5 h of symptom onset and of those 260 (62%) received reperfusion therapy (IVRTPA alone, n = 183; combination or bridging therapy, n = 60; EST alone, n = 17). Subtracting cases with absolute contraindications for IVRTPA resulted in an effective thrombolysis rate of 82%. sICH occurred in two patients treated with IVRTPA alone (1.1%). The median door-to-needle interval was 30 min. Fifty (17%) non-EST eligible AIS patients presenting within 4.5 h without absolute contraindications did not receive IVRTPA mainly due to mild or regressive symptoms. Most of these untreated IVRTPA eligible patients (82%) were discharged with a good clinical outcome (modified Rankin Scale ≤ 2). CONCLUSIONS Intravenous recombinant tissue plasminogen activator remains the most frequently applied reperfusion therapy in AIS patients presenting within 4.5 h of onset in a tertiary stroke centre. An effective thrombolysis rate of over 80% can be achieved without increased rates of sICH.
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Affiliation(s)
- S Feda
- Department of Neurology, RWTH Aachen University, Aachen, Germany.,Department of Nephrology, RWTH Aachen University, Aachen, Germany
| | - O Nikoubashman
- Department of Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - K Schürmann
- Department of Neurology, RWTH Aachen University, Aachen, Germany
| | - O Matz
- Department of Neurology, RWTH Aachen University, Aachen, Germany.,Emergency Department, RWTH Aachen University, Aachen, Germany
| | - S C Tauber
- Department of Neurology, RWTH Aachen University, Aachen, Germany
| | - M Wiesmann
- Department of Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - J B Schulz
- Department of Neurology, RWTH Aachen University, Aachen, Germany.,JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH, RWTH Aachen University, Aachen, Germany
| | - A Reich
- Department of Neurology, RWTH Aachen University, Aachen, Germany
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