Prior IV Thrombolysis Facilitates Mechanical Thrombectomy in Acute Ischemic Stroke

Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion

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.

Predictive Factors of First-Pass Effect in Patients Who Underwent Successful Endovascular Thrombectomy for Emergent Large Vessel Occlusion

OBJECTIVE

The primary treatment goal of current endovascular thrombectomy (EVT) for emergent large-vessel occlusion (ELVO) is complete recanalization after a single maneuver, referred to as the 'first-pass effect' (FPE). Hence, we aimed to identify the predictive factors of FPE and assess its effect on clinical outcomes in patients with ELVO of the anterior circulation.

METHODS

Among the 129 patients who participated, 110 eligible patients with proximal ELVO (intracranial internal carotid artery and proximal middle cerebral artery) who achieved successful recanalization after EVT were retrospectively reviewed. A comparative analysis between patients who achieved FPE and all others (defined as a non-FPE group) was performed regarding baseline characteristics, clinical variables, and clinical outcomes. Multivariate logistic regression analyses were subsequently conducted for potential predictive factors with p<0.10 in the univariate analysis to determine the independent predictive factors of FPE.

RESULTS

FPE was achieved in 31 of the 110 patients (28.2%). The FPE group had a significantly higher level of functional independence at 90 days than did the non-FPE group (80.6% vs. 50.6%, p=0.002). Pretreatment intravenous thrombolysis (IVT) (odds ratio [OR], 3.179; 95% confidence interval [CI], 1.025-9.861; p=0.045), door-to-puncture (DTP) interval (OR, 0.959; 95% CI, 0.932-0.987; p=0.004), and the use of balloon guiding catheter (BGC) (OR, 3.591; 95% CI, 1.231-10.469; p=0.019) were independent predictive factors of FPE.

CONCLUSION

In conclusion, pretreatment IVT, use of BGC, and a shorter DTP interval were positively associated with FPE, increasing the chance of acquiring better clinical outcomes.

In a hub-and-spoke network, spoke-administered thrombolysis reduces mechanical thrombectomy procedure time and number of passes

BACKGROUND

The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion stroke (LVO) is controversial. Some data suggest IVT increases MT technical difficulty. Within our hub-and-spoke telestroke network, we examined how spoke-administered IVT affected hub MT procedure time and pass number.

METHODS

Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. MT procedure time, fluoroscopy time, and pass number were obtained from operative reports.

RESULTS

Of 107 patients, 48 received IVT at spokes. Baseline characteristics and NIHSS were similar. The last known well (LKW)-to-puncture time was shorter among IVT patients (4.3 ± 1.9 h vs. 10.5 ± 6.5 h, p < 0.0001). In patients that received IVT, mean MT procedure time was decreased by 18.8 min (50.5 ± 29.4 vs. 69.3 ± 46.7 min, p = 0.02) and mean fluoroscopy time was decreased by 11.3 min (21.7 ± 15.8 vs. 33.0 ± 30.9 min, p = 0.03). Furthermore, IVT-treated patients required fewer MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p = 0.0002) and were more likely to achieve reperfusion in ≤2 passes (81.3% vs. 59.3%, p = 0.01). An increased proportion of IVT-treated patients achieved TICI 2b-3 reperfusion after MT (93.9% vs. 83.8%, p = 0.045). There were no associations between MT procedural characteristics and LKW-to-puncture time.

CONCLUSION

Within our network, hub MT following spoke-administered IVT was faster, required fewer passes, and achieved improved reperfusion. This suggests spoke-administered IVT does not impair MT, but instead may enhance it.

Mechanical thrombectomy combined with intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analyses

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.

Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe

The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area.

Effect of intravenous thrombolysis on core growth rate in patients with acute cerebral infarction

Objective

This study aimed to investigate the effects of recombinant tissue plasminogen activator intravenous thrombolysis (IVT) on the core growth rate of acute ischemic stroke.

Methods

Stroke patients with large vessel occlusion and non-recanalization from IVT treatment were retrospectively included in this study and divided into two groups: IVT and non-IVT. The core growth rate was estimated by the acute core volume on perfusion CT divided by the last known well time from stroke to CT perfusion. The primary endpoint was the core growth rate, the tissue outcome was 24 h-ASPECTS, and the clinical outcome was a 3-month modified Rankin score.

Results

A total of 94 patients were included with 53 in the IVT group and 41 in the non-IVT group. There was no significant difference in age, gender, hypertension, diabetes, atrial fibrillation, acute NIHSS, and last known well time from stroke to CT perfusion acquisition between the two groups. The core growth rate in the IVT group was lower than that in the non-IVT group, which was statistically significant after multivariate adjustment (coefficient: -5.20, 95% CI= [-9.85, -0.56], p = 0.028). There was a significant interaction between the IVT and the collateral index in predicting the core growth rate. The analysis was then stratified according to the collateral index, and the results suggested that IVT reduced the core growth rate more significantly after the worsening of collateral circulation (coefficient: 15.38, 95% CI= [-26.25, -4.40], p = 0.007). The 3-month modified Rankin score and 24 h-ASPECTS were not statistically significant between the two groups.

Conclusion

Intravenous thrombolysis reduces the core growth rate in patients with AIS, especially those with poor collateral status.

Intravenous thrombolysis before thrombectomy in acute ischemic stroke: a dual centre retrospective cohort study

First pass effect (FPE) is a successful recanalization (mTICI ≥ 2b) after the first trial of thrombectomy. It is associated with good functional outcomes. Few studies discussed the effect of BT (bridging therapy: combined I.V. thrombolysis and mechanical thrombectomy) on FPE and clinical outcomes. In our study, we would like to report the effect of MT with or without preceding IVT on FPE and the functional outcome of AIS (Acute Ischemic Stroke) of anterior circulation in real practice. A dual-center retrospective cohort study enrolled 201 patients with AIS of anterior circulation and was divided into a bridging therapy (BT) group of 150 patients who received alteplase preceding thrombectomy, and a direct mechanical thrombectomy (dMT) group of 51 patients. Comparisons between both groups regarding the clinical and radiological outcome. Early better clinical outcome (mRS ≤ 2) at day seven with BT group (39.3%) rather than dMT (23.5%) with P value = 0.044. No significant differences as regard puncture to revascularization time, successful revascularization (mTICI) ≥ 2b and FPE between both groups (P value: 0.328, 0.538, and 0.708, respectively). No differences as regards hemorrhagic transformation, mortality rate, and 90-day favorable outcome between both groups (P value 0.091, 0.089, and 0.192, respectively). BT might have better early outcome than dMT but no difference as regards 90-day favorable outcomes, mortality, sICH, FPE, recanalization rate and procedure time. It might be reasonable to go directly to mechanical thrombectomy without IVT for AIS with large vessel occlusion.

Predictive Factors for Clinical Outcome After Direct Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion Within 4.5 h

Background

Recent trials including DIRECT-MT, DEVT, and SKIP have found that direct mechanical thrombectomy (MT) is equally effective as the combination of MT and intravenous thrombolysis. However, the results of the other trials, namely MR-CLEAN NO-IV and the SWIFT-DIRECT trial have failed to confirm the non-inferiority of direct MT vs. the combination therapy.

Aim

We aimed to identify prognostic factors of direct MT for anterior circulation large vessel occlusion within 4.5 h.

Materials and Methods

Data from January 2018 to January 2022 were retrospectively collected and analyzed. Adult patients with confirmed anterior circulation large vessel occlusion within 4.5 h of onset with baseline NIHSS of ≥6 and baseline ASPECTS of ≥6 treated using direct MT within 6 h were recruited.

Results

A total of 140 patients were enrolled in the study with a median age of 65.5 years [interquartile range (IQR), 59–76.5], median baseline NIHSS of 13.5 (IQR, 11–16), and median baseline ASPECTS of 8 (IQR, 7–8). Direct MT was feasible in all patients (100%). Successful reperfusion (mTICI 2b-3) was achieved in 124/140 patients (88.6%) with a low rate of complications (8/140, 5.7%). Any type of intracranial hemorrhage (ICH) and symptomatic ICH occurred in 44/140 (31.4%) and 5/140 (3.6%), respectively. Overall, a good outcome (mRS 0–2) was achieved in 93/140 (66.4%), and the mortality rate was 9.3% (13/140 patients). Using multivariate analysis, lower age [odds ratio (OR), 0.96; 95% CI, 0.92–1.00; P = 0.05], low baseline NIHSS (OR, 0.82; 95% CI, 0.74–0.92; P = 0.00), and absence of ICH (OR, 0.29; 95% CI, 0.10–0.81; P = 0.02) were independently associated with favorable outcome. Independent predictors of mortality were baseline NIHSS (OR, 1.21; 95% CI, 1.01–1.46; P = 0.04), successful reperfusion (OR, 0.02; 95% CI, 0.00–0.58; P = 0.02), and ICH (OR, 0.12; 95% CI, 0.02–0.75; P = 0.02). Further analysis showed that the median mRS at 90 days was significantly better in the MCA occlusion group compared to the ICA plus M1 occlusion group [1 (IQR 0–3) vs. 2 (IQR 1–4); P = 0.05].

Conclusions

Our findings suggest that direct thrombectomy may be an adequate clinical option for younger patients (≤70) experiencing proximal middle artery occlusion within 4.5 h and who have low baseline NIHSS (≤14).

Effect of Occlusion Site on the Safety and Efficacy of Intravenous Alteplase Before Endovascular Thrombectomy: A Prespecified Subgroup Analysis of DIRECT-MT

BACKGROUND AND PURPOSE

Recent trials showed thrombectomy alone was comparable to bridging therapy in patients with anterior circulation large vessel occlusion eligible for both intravenous alteplase and endovascular thrombectomy. We performed this study to examine whether occlusion site modifies the effect of intravenous alteplase before thrombectomy.

METHODS

This is a prespecified subgroup analysis of a randomized trial evaluating risk and benefit of intravenous alteplase before thrombectomy (DIRECT-MT [Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals]). Among 658 randomized patients, 640 with baseline occlusion site information were included. The primary outcome was the score on the modified Rankin Scale at 90 days. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by occlusion location (internal carotid artery versus M1 versus M2). We report the adjusted common odds ratio for a shift toward better outcome on the modified Rankin Scale after thrombectomy alone compared with combination treatment adjusted for age, the National Institutes of Health Stroke Scale score at baseline, the time from stroke onset to randomization, the modified Rankin Scale score before stroke onset, and collateral score per the DIRECT-MT statistical analysis plan.

RESULTS

The overall adjusted common odds ratio was 1.08 (95% CI, 0.82-1.43) with thrombectomy alone compared with combination treatment, and there was no significant treatment-by-occlusion site interaction (P=0.47). In subgroups based on occlusion location, we found the following adjusted common odds ratios: 0.99 (95% CI, 0.62-1.59) for internal carotid artery occlusions, 1.12 (95% CI, 0.77-1.64) for M1 occlusions, and 1.22 (95% CI, 0.53-2.79) for M2 occlusions. No treatment-by-occlusion site interactions were observed for dichotomized modified Rankin Scale distributions and successful reperfusion (extended thrombolysis in Cerebral Infarction score ≥2b) before thrombectomy. Differences in symptomatic hemorrhage rate were not significant between occlusion locations (internal carotid artery occlusion: 7.02% in bridging therapy versus 7.14% for thrombectomy alone, P=0.97; M1 occlusion: 5.06% versus 2.48%, P=0.22; M2 occlusion: 9.09% versus 4.76%; P=0.78).

CONCLUSIONS

In this prespecified subgroup of a randomized trial, we found no evidence that occlusion location can inform intravenous alteplase decisions in endovascular treatment eligible patients directly presenting at endovascular treatment capable centers. Future studies are needed to confirm our findings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.

Recanalization Treatment of Acute Ischemic Stroke Caused by Large-Artery Occlusion in the Elderly: A Comparative Analysis of "the Elderly" and "the Very Elderly"

OBJECTIVE

To assess whether the effectiveness and safety of recanalization therapy for acute ischemic stroke (AIS) caused by large-artery occlusion (LAO) differ between patients aged 60-79 years and patients aged ≥80 years.

METHODS

We analyzed prospective data of patients with LAO (≥60 years) who underwent recanalization therapy at the Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, PLA Rocket Force Characteristic Medical Center, from November 2013 to July 2017. The data were compared between elderly patients (60-79 years) and very elderly patients (≥80 years). The effectiveness of recanalization therapy was evaluated using the 90-day modified Rankin scale (mRS) score, while safety was assessed by the rates of symptomatic intracranial hemorrhage (SICH) and mortality within 30 days.

RESULTS

A total of 151 patients with AIS induced by LAO were included in this study. Seventy-three patients (48.3% [73/151]) had an overall favorable outcome (mRS score 0-2) after treatment. A higher proportion of patients in the elderly group showed a favorable outcome compared with the very elderly group (58.6% [34/58] vs. 41.6% [39/93], respectively; P = 0.046). The incidence of SICH (12.7% vs. 16.13%, respectively; P = 0.561) and mortality (10.3% vs. 7.5%, respectively; P = 0.548) within 30 days was not significantly different between the two groups.

CONCLUSION

Recanalization treatment of LAO is more effective in elderly patients compared with very elderly patients, while the safety of recanalization treatment is comparable between these two groups.

Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1?

BACKGROUND

The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase.

METHODS

We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost.

RESULTS

When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis.

CONCLUSION

EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.

Comparison of Prior Bridging Intravenous Thrombolysis With Direct Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion: Systematic Review and Meta-Analysis

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.

Bridging Therapy and Occlusion Site Influence Symptomatic Hemorrhage Rate after Thrombectomy: A Daily Practice Study in 623 Stroke Patients

BACKGROUND

Comparison of symptomatic intracranial hemorrhage (SICH) rates between stroke patients treated with bridging therapy (BT) and primary mechanical thrombectomy (PMT) are scarce and difficult to interpret due to baseline differences between both populations.

METHODS

Retrospective analysis of patients with acute ischemic stroke treated with endovascular therapy (BT or PMT) was performed at our center between January 2010 and June 2017.

RESULTS

Six hundred twenty-three patients were included. Global SICH rate was 9% overall: 6.8% in the PMT group and 12.6% in the BT group. The following factors significantly associated with SICH after multivariate analysis: MCA occlusion (p: 0.047), stroke of unknown origin (p: 0.025), BT (p: 0.024), and procedural time over 65 min (p: 0.027). The following variables presented a statistically significant higher frequency in patients treated with PMT: atrial fibrillation (p: 0.005), anticoagulant medication (p < 0.001), wake-up strokes (p < 0.001), atherothrombotic etiology (p < 0.05), combined thrombectomy technique (p: 0.008), longer procedural times (p: 0.025), and favorable outcome at 3 months (p: 0.011). The following variables presented a statistically significant higher frequency in patients treated with BT: antiplatelet medication (p: 0.048), MCA occlusions (p: 0.017), cardioembolic etiology (p < 0.05), stent retriever/aspiration technique (p: 0.008), and SICH (p: 0.013). Patients with MCA occlusions had twice the risk of SICH after BT than after PMT (16.4 and 8.6%, p: 0.038).

CONCLUSIONS

In this clinical series, the SICH rate was higher in patients treated with BT than in those treated with PMT. Relevant differences in baseline (related to IVT contraindications) were found between both groups. Randomized studies of BT versus PMT in populations with similar baseline characteristics might be of interest.

Endovascular Treatment With and Without Intravenous Thrombolysis in Large Vessel Occlusions Stroke: A Systematic Review and Meta-Analysis

Background: Previous studies have shown conflicting results about the benefits of pretreatment with intravenous thrombolysis before endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) with large vessel occlusions (LVOs). This study aimed to investigate the clinical efficacy and safety of EVT alone vs. bridging therapy (BT) in patients with AIS with LVOs. Methods: A systematic review with meta-analysis of all available studies comparing clinical outcomes between BT and EVT alone was conducted by searching the National Center for Biotechnology Information/National Library of Medicine PubMed and Web of Science databases for relevant literature from database inception to October 20, 2020. Results: A total of 93 studies enrolling 45,190 patients were included in the present analysis. In both unadjusted and adjusted analyses, BT was associated with a higher likelihood of 90-day good outcome (crude odds ratio [cOR] 1.361, 95% confidence interval [CI] 1.234-1.502 and adjusted OR [aOR] 1.369, 95% CI 1.217-1.540) and successful reperfusion (cOR 1.271, 95% CI 1.149-1.406 and aOR 1.267, 95% CI 1.095-1.465) and lower odds of 90-day mortality (cOR 0.619, 95% CI 0.560-0.684 and aOR 0.718, 95% CI 0.594-0.868) than EVT alone. The two groups did not differ in the occurrence of symptomatic intracranial hemorrhage (sICH) (cOR 1.062, 95% CI 0.915-1.232 and aOR 1.20, 95% CI 0.95-1.47), 24-h early recovery (cOR 1.306, 95% CI 0.906-1.881 and aOR 1.46, 95% CI 0.46-2.19), and number of thrombectomy device passes ≤ 2 (aOR 1.466, 95% CI 0.983-2.185) after sensitivity analyses and adjustment for publication bias. Conclusions: BT provides more benefits than EVT alone in terms of clinical functional outcomes without compromising safety in AIS patients with LVOs.

Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of "Drip and Ship" on Effectiveness and Outcomes

Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital. Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes. Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h. Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.

Early Recanalization With Alteplase in Stroke Because of Large Vessel Occlusion in the ESCAPE Trial

BACKGROUND AND PURPOSE

Quantitating the effect of intravenous alteplase on the technical outcome of early recanalization of large vessel occlusions aids understanding. We report the prevalence of early recanalization in patients with stroke because of large vessel occlusion treated with and without intravenous alteplase and endovascular thrombectomy, and its association with clinical outcome.

METHODS

Patients with acute ischemic stroke with large vessel occlusion from the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times Trial) were included in this post hoc analysis. Outcomes of interest were the prevalence of early recanalization (1) and good outcome (2), defined as modified Rankin Scale score of 0 to 2 at 90 days.

RESULTS

Among 147 patients who did not receive endovascular thrombectomy, early recanalization occurred in 4/30 (13.3%) patients without and 48/117 (41.0%) patients with intravenous alteplase (adjusted risk ratios, 3.2 [95% CI, 1.2-8.1]). Good outcome was achieved by 34/116 (29.3%) of patients who received intravenous alteplase versus 10/29 (34.5%) who did not receive alteplase (adjusted risk ratios, 1.0 [95% CI, 0.6-1.5) and by 20/52 (38.5%) patients with versus 24/93 (25.8%) without early recanalization (adjusted risk ratios, 1.9 [95% CI, 1.2-2.9]).

CONCLUSIONS

Early recanalization was confirmed as a strong predictor of good outcome in patients who did not undergo endovascular thrombectomy and was improved with intravenous alteplase, yet a majority of patients (59.0%) did not achieve early reperfusion. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01778335.

Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry

PURPOSE

Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional outcomes. With data obtained from the Taiwan registry, the factors associated with mTICI 3 recanalization and clinical outcomes in EVT are investigated.

METHODS

From January 2014 to September 2016, 108 patients who underwent EVT for AIS due to LVO in 11 medical centers throughout Taiwan were included. Complete recanalization is defined as achieving modified thrombolysis in cerebral infarction (mTICI) grade 3. Good clinical outcomes are defined by the modified Rankin scale (mRS) 0-2 at 3 months after EVT. Clinical and imaging parameters for predicting mTICI 3 recanalization and good clinical outcomes are analyzed.

RESULTS

Of the 108 patients who received EVT, 54 (50%) patients had mTICI 3 recanalization. Having received aspiration only and the use of IV-tPA are shown to be significant predictors for mTICI 3 recanalization with odds ratios of 2.61 and 2.53 respectively. Forty-six (42.6%) patients experienced good 3-month clinical outcomes (mRS 0-2). Pretreatment collateral statuses, NIHSS scores, time lapses between symptoms to needle, and the occurrence of hemorrhage at 24 h are all significant predictors for good outcomes with odds ratios of 2.88, 0.91, 0.99, and 0.31 respectively.

CONCLUSIONS

Prediction of mTICI 3 recanalization and clinical outcomes offer valuable clinical information for treatment planning in EVT.

Intravenous r-tPA Dose Influence on Outcome after Middle Cerebral Artery Ischemic Stroke Treatment by Mechanical Thrombectomy

Background and Objectives: Pretreatment with intravenous thrombolysis (IVT) is still recommended in all eligible acute ischemic stroke patients with large-vessel occlusion before mechanical thrombectomy (MTE). However, the added value and safety of bridging therapy versus direct MTE remains controversial. We aimed at evaluating the influence of r-tPA dose level in patients with middle cerebral artery (MCA) occlusion treated with MTE. Materials and Methods: We prospectively compared clinical and radiological outcomes in 38 bridging patients, with 65 receiving direct MTE for MCA stroke admitted to Vilnius University Hospital Santaros Clinics. Following our protocol, r-tPA infusion was stopped just before MTE in the operating room. Therefore, we divided all bridging patients into three groups according to the amount of r-tPA they received: bolus, partial dose or full dose. Functional independence at 90 days was assessed by a modified Rankin Scale score, i.e., from 0–2. The safety outcomes included 90-day mortality and any intracerebral hemorrhage (ICH). Results: Baseline characteristics and functional outcome at 90 days did not differ between the bridging and direct MTE groups. Shorter MTE procedure and hospitalization time (p = 0.025 and p = 0.036, respectively) were observed in the direct MTE group. An IVT treatment subgroup analysis showed higher rates of symptomatic ICH (p < 0.001) and longer intervals between imaging to MTE (p = 0.005) in the full r-tPA dose group. Conclusions: In patients with an MCA stroke, direct MTE seems to be a safe and equally effective as bridging therapy. The optimal r-tPA dose remains unclear. Randomized trials are needed to accurately evaluate the added value of r-tPA in patients treated with MTE.

Bridging Intravenous Thrombolysis Before Mechanical Thrombectomy for Large Artery Occlusion May be Detrimental with Thrombus Fragmentation

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.

Does Intravenous Thrombolysis Influence the Time of Recanalization and Success of Mechanical Thrombectomy during the Acute Phase of Cerebral Infarction?

Objectives

Mechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke (AIS) caused by large vessel occlusion. Recanalization time is a key factor in the treatment of AIS. It has previously been suggested that intravenous thrombolysis (IVT) may be associated with a shorter recanalization time. The aim of our study was to investigate whether IVT or other factors could be associated with shorter or longer MT procedure times.

Methods

We performed a retrospective analysis of a local cohort of patients treated by MT. We collected procedure time (puncture to recanalization and clot visualization to recanalization), demographic data, localization of the thrombus, antithrombotic treatment at arrival, IVT infusion, and stroke subtype at discharge according to the TOAST classification. We planned to analyze the full cohort and the successful revascularization subgroup.

Results

There was no difference in procedure times between patients who received IVT and those who did not. In the successful revascularization subgroup, patients presenting with cardioembolic stroke had a significantly shorter time between clot visualizations and revascularization than the other patients (41 vs. 56 min, p = 0.024), but this was not the case in the full cohort. Also in the successful revascularization subgroup, the revascularization time was 76 vs. 61 min (p = 0.075) in patients presenting with tandem occlusion vs. the others, but there was no difference between these groups in the full cohort.

Conclusions

There was no difference in terms of procedure times in patients treated by IVT and MT vs. patients treated by MT alone either in the full cohort or in the successful revascularization subgroup. The data from the successful revascularization subgroup may be useful for studying revascularization times, provided that data from procedures that were stopped prematurely by the operator due to the length of time since symptom onset is removed.

Outcomes of mechanical thrombectomy with pre-intravenous thrombolysis: a systematic review and meta-analysis

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.

How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT

BACKGROUND AND PURPOSE

With increasing use of endovascular therapy, physicians' attitudes toward intravenous alteplase in endovascular therapy-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians in endovascular therapy- and alteplase-eligible patients with acute stroke using prespecified case scenarios and compared how their current local treatment practices differ compared with an assumed ideal environment.

MATERIALS AND METHODS

In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case scenarios, among them 14 with guideline-based alteplase recommendations (9 with level 1A and 5 with level 2B recommendation) and were asked how they would treat the patient: A) under their current local resources, and B) under assumed ideal conditions. Answer options were the following: 1) anticoagulation/antiplatelet therapy, 2) endovascular therapy, 3) endovascular therapy plus intravenous alteplase, and 4) intravenous alteplase. Decision rates were calculated, and multivariable regression analysis was performed to determine variables associated with the decision to abandon intravenous alteplase.

RESULTS

In cases with guideline recommendations for alteplase, physicians favored alteplase in 82.0% under current local resources and in 79.3% under assumed ideal conditions (P < .001). Under assumed ideal conditions, interventional neuroradiologists would refrain from intravenous alteplase most often (6.28%, OR = 2.40; 95% CI, 1.01-5.71). When physicians' current and ideal decisions differed, most would like to add endovascular therapy to intravenous alteplase in an ideal setting (196/3861 responses, 5.1%).

CONCLUSIONS

In patients eligible for endovascular therapy and intravenous alteplase, we observed a slightly lower decision rate in favor of intravenous alteplase under assumed ideal conditions compared with the decision rate under current local resources.

The prediction of acute ischemic stroke patients' long-term functional outcomes treated with bridging therapy

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.

Is intravenous thrombolysis still necessary in patients who undergo mechanical thrombectomy?

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.

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

INTRODUCTION

One uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)).

OBJECTIVE

To evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT.

METHODS

Consecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated.

RESULTS

A total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11-20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p<0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005).

CONCLUSIONS

IVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT.

Combined intravenous and endovascular treatment versus primary mechanical thrombectomy. The Italian Registry of Endovascular Treatment in Acute Stroke

Background

Whether mechanical thrombectomy alone may achieve better or at least equal clinical outcome than mechanical thrombectomy combined with intravenous thrombolysis is a matter of debate.

Methods

From the Italian Registry of Endovascular Stroke Treatment, we extracted all cases treated with intravenous thrombolysis followed by mechanical thrombectomy or with primary mechanical thrombectomy for anterior circulation stroke due to proximal vessel occlusion. We included only patients who would have qualified for intravenous thrombolysis. We compared outcomes of the two groups by using multivariate regression analysis and propensity score method.

Results

We included 1148 patients, treated with combined intravenous thrombolysis and mechanical thrombectomy therapy (n = 635; 55.3%), or with mechanical thrombectomy alone (n = 513; 44.7%). Demographic and baseline clinical characteristics did not differ between the two groups, except for a shorter onset to groin puncture time (p < 0.05) in the mechanical thrombectomy group. A shift in the 90-day modified Rankin Scale distributions toward a better outcome was found in favor of the combined treatment (adjusted common odds ratio  = 1.3; 95% confidence interval: 1.04–1.66). Multivariate analyses on binary outcome show that subjects who underwent combined treatment had higher probability to survive with modified Rankin Scale 0–3 (odds ratio = 1.42; 95% confidence interval: 1.04–1.95) and lower case fatality rate (odds ratio = 0.6; 95% confidence interval: 0.44–0.9). Hemorrhagic transformation did not differ between the two groups.

Conclusion

These data seem to indicate that combined intravenous thrombolysis and mechanical thrombectomy could be associated with lower probability of death or severe dependency after three months from stroke due to large vessel occlusion, supporting the current guidelines of treating eligible patients with intravenous thrombolysis before mechanical thrombectomy.

Impact of pretreatment with intravenous thrombolysis on reperfusion status in acute strokes treated with mechanical thrombectomy

Introduction

We sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center.

Methods

Consecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented.

Results

A total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0–2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33–70) vs 70 (IQR 44–98) min; p<0.001). Among patients who achieved SR (n=292), the median number of required device passes was lower in the IVT+MT subgroup (1 (IQR 1–1) vs 2 (IQR 1–2); p<0.001), while the rate of patients requiring ≤2 device passes was higher (98% vs 77%; p<0.001). IVT+MT was independently related to higher odds of SR (OR 1.64; 95% CI 1.03 to 2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient −20.39; 95% CI −27.56 to –13.22; p<0.001) on multivariable analyses adjusting for potential confounders. Among patients with SR, IVT+MT was independently associated with a higher likelihood of ≤2 device passes (OR 14.63; 95% CI 4.46 to 48.00; p<0.001).

Conclusions

IVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT.

Effectiveness of Low-Dose Intravenous Tissue Plasminogen Activator before Stent Retriever or Aspiration Mechanical Thrombectomy

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.

Comparative efficacy and safety of bridging strategies with direct mechanical thrombectomy in large vessel occlusion: A systematic review and meta-analysis

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.

Bridging Therapy Versus Direct Mechanical Thrombectomy in Patients with Acute Ischemic Stroke due to Middle Cerebral Artery Occlusion: A Clinical- Histological Analysis of Retrieved Thrombi

Mechanical thrombectomy (MT) is effective in managing patients with acute ischemic stroke (AIS) caused by large-vessel occlusions and allows for valuable histological analysis of thrombi. However, whether bridging therapy (pretreatment with intravenous thrombolysis before MT) provides additional benefits in patients with middle cerebral artery (MCA) occlusion remains unclear. Therefore, this study aimed to compare the effects of direct MT and bridging therapy, and to elucidate the correlation between thrombus composition and stroke subtypes. Seventy-three patients with acute ischemic stroke who received MT, were eligible for intravenous thrombolysis, and had MCA occlusion were included. We matched 21 direct MT patients with 21 bridging therapy patients using propensity score matching and compared their 3rd-month clinical outcomes. All MCA thrombi (n = 45) were histologically analyzed, and the red blood cell (RBC) and fibrin percentages were quantified. We compared the clot composition according to stroke etiology (large-artery atherosclerosis and cardioembolism) and intravenous thrombolysis application. The baseline characteristics showed no difference between groups except for a higher atrial fibrillation rate and NIHSS score on admission in the direct MT group. We performed a supportive analysis using propensity score matching but could not find any differences in the functional outcome, mortality, and intracerebral hemorrhage. In the histological clot analysis, the cardioembolic clots without intravenous thrombolysis pretreatment had higher RBC (P = 0.042) and lower fibrin (P = 0.042) percentages than the large-artery atherosclerosis thrombi. Similar findings were observed in the thrombi treated with recombinant tissue plasminogen activator (P = 0.012). In conclusion, there was no difference in the functional outcomes between the direct MT and bridging therapy groups. However, randomized trials are needed to elucidate the high ratio of cardioembolism subtype in our group of patients. The histological MCA thrombus composition differed between cardioembolism and large-artery atherosclerosis, and this finding provides valuable information on the underlying pathogenesis and thrombus origin.

Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis

BACKGROUND

Whether pretreatment with intravenous thrombolysis prior to mechanical thrombectomy (IVT+MTE) adds additional benefit over direct mechanical thrombectomy (dMTE) in patients with large vessel occlusions (LVO) is a matter of debate.

METHODS

This study-level meta-analysis was presented in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled effect sizes were calculated using the inverse variance heterogeneity model and displayed as summary Odds Ratio (sOR) and corresponding 95% confidence interval (95% CI). Sensitivity analysis was performed by distinguishing between studies including dMTE patients eligible for IVT (IVT-E) or ineligible for IVT (IVT-IN). Primary outcome measures were functional independence (modified Rankin Scale≤2) and mortality at day 90, successful reperfusion, and symptomatic intracerebral hemorrhage.

RESULTS

Twenty studies, incorporating 5279 patients, were included. There was no evidence that rates of successful reperfusion differed in dMTE and IVT+MTE patients (sOR 0.93, 95% CI 0.68 to 1.28). In studies including IVT-IN dMTE patients, patients undergoing dMTE tended to have lower rates of functional independence and had higher odds for a fatal outcome as compared with IVT+MTE patients (sOR 0.78, 95% CI 0.61 to 1.01 and sOR 1.45, 95% CI 1.22 to 1.73). However, no such treatment group effect was found when analyses were confined to cohorts with a lower risk of selection bias (including IVT-E dMTE patients).

CONCLUSION

The quality of evidence regarding the relative merits of IVT+MTE versus dMTE is low. When considering studies with lower selection bias, the data suggest that dMTE may offer comparable safety and efficacy as compared with IVT+MTE. The conduct of randomized-controlled clinical trials seems justified.

Is Direct Endovascular Treatment as an Alternative of Bridging Therapy in Acute Stroke Patients with Large Vessel Occlusion?

BACKGROUND

Although endovascular treatment (EVT) is very effective for acute ischemia stroke (AIS) patients with proximal large vessels occlusion (LVO), whether bridging rPA before EVT in stroke patients of LVO is of any benefit and is currently one of the most urgent unanswered questions. We aim to comprehensively determine the efficacy and safety of direct EVT (DEVT) in AIS patients with LVO versus bridging therapy (BT).

METHODS

Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to May 2017 were identified for analysis. Two reviewers extracted data and conducted quality assessment independently. Statistical tests were performed to check for heterogeneity and publication bias. Subgroup and sensitivity analysis were also conducted to evaluate the robustness of the conclusions.

RESULTS

Overall, 13 studies involving 3302 patients met the inclusion criteria. The AIS patients with DEVT had a similar likelihood to achieve good functional outcome at 3 months (risk ratio [RR] = .93, 95% confidence interval [CI] = .85-1.01, P = .094), mortality at 3 months (RR = 1.10, 95% CI = .91-1.33, P = .33), and symptomatic intracranial hemorrhage (RR = 1.06, 95% CI = .74-1.51, P = .75) versus BT; furthermore, the risk of intracranial hemorrhage was lower in DEVT group (RR = .76, 95% CI = .60-.95, P = .02). No significant difference in recanalization rate existed between the 2 groups (RR = .97, 95% CI = .92-1.02, P = .22); however, in the subgroup analysis, it had a rise trend after DEVT than BT in IVT-eligible group (RR = 1.45, 95% CI = .95-2.22, P = .09).

CONCLUSIONS

DEVT appears to have equally effectiveness to BT with a low risk of intracranial hemorrhage in AIS patients with LVO, especially for anterior circulation, which offered a practical information to select appropriate therapeutic strategies for patients with LVO, though the level of evidence seems to be quite shaky.

Comparison of Mechanical Thrombectomy with Contact Aspiration, Stent Retriever, and Combined Procedures in Patients with Large-Vessel Occlusion in Acute Ischemic Stroke

Background

We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed.

Material/Methods

This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59).

Results

ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0–2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0–2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015).

Conclusions

Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.

Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Background and purpose

We aimed to identify the best definition of early neurological improvement (ENI) at 2 and 24 hours after mechanical thrombectomy (MT) and determine its ability to predict a good functional outcome at 3 months.

Methods

This retrospective analysis was based on a prospectively collected registry of patients treated by MT for ischemic stroke from May 2010 to March 2017. We included patients treated with stent-retrievers with National Institute of Health Stroke Scale (NIHSS) score before treatment and at 2 and/or 24 hours after treatment and modified Rankin Score (mRS) at 3 months. Receiver operating characteristic curve analysis was performed to estimate optimal thresholds for ENI at 2 and 24 hours. The relationship between optimal ENI definitions and good outcome at 3 months (mRS 0–2) was assessed by logistic regression.

Results

The analysis included 246 patients. At 2 hours, the optimal threshold to predict a good outcome at 3 months was improvementin the NIHSS score of >1 point (AUC 0.83,95% CI 0.77 to 0.87), with sensitivity and specificity 78.3% (62.2–85.7%) and 84.6% (77.2–90.3%), respectively, and OR 12.67 (95% CI 4.69 to 31.10, p<0.0001). At 24 hours, the optimal threshold was an improvementin the NIHSS score of >4 points (AUC 0.93, 95% CI 0.89 to 0.96), with sensitivity and specificity 93.8% (87.7–97.5%) and 83.2% (75.7–89.2%), respectively, and OR 391.32 (95% CI 44.43 to 3448.35, p<0.0001).

Conclusions

ENI 24 hours after thrombectomy appears to be a straightforward surrogate of long-term endpoints and may have value in future research.

Carotid Artery Stenosis Contralateral to Intracranial Large Vessel Occlusion: An Independent Predictor of Unfavorable Clinical Outcome After Mechanical Thrombectomy

Background: Clinical outcome in patients undergoing mechanical thrombectomy (MT) due to intracranial large vessel occlusion (LVO) in the anterior circulation is influenced by several factors. The impact of a concomitant extracranial carotid artery stenosis (CCAS) contralateral to the intracranial lesion remains unclear. Methods: Retrospective analysis of 392 consecutive patients treated with MT due to intracranial LVO in the anterior circulation in two comprehensive stroke centers between 2014 and 2017. Clinical (including demographics and NIHSS), imaging (including angiographic evaluation of CCAS via NASCET criteria), and procedural data were evaluated. Primary endpoint was an unfavorable clinical outcome defined as modified Rankin Scale 3-6 at 90 days. Results: In 27/392 patients (7%) pre-interventional imaging exhibited a CCAS (>50%) contralateral to the intracranial lesion compared to 365 patients without relevant stenosis. Median baseline NIHSS, procedural timings, and reperfusion success did not differ between groups. Median volume of the final infarct core was larger in CCAS patients (176 cm³, IQR 32-213 vs. 11 cm³, 1-65; p < 0.001). At 90 days, unfavorable outcome was documented in 25/27 CCAS patients (93%) vs. 211/326 (65%; p = 0.003) with a mortality of 63 vs. 19% (p = 0.001), respectively. Presence of CCAS was associated with an unfavorable outcome at 90 days independent of age and baseline NIHSS in multivariate logistic regression (OR 2.2, CI 1.1-4.7; p < 0.05). Conclusion: For patients undergoing MT due to intracranial vessel occlusion in the anterior circulation, the presence of a contralateral CCAS >50% is a predictor of unfavorable clinical outcome at 90 days.

Intravenous Recombinant Tissue-Type Plasminogen Activator: Influence on Outcome in Anterior Circulation Ischemic Stroke Treated by Mechanical Thrombectomy

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.

Short and long-term outcomes after combined intravenous thrombolysis and mechanical thrombectomy versus direct mechanical thrombectomy: a prospective single-center study

Recent clinical trials demonstrated that mechanical thrombectomy (MT) using second-generation endovascular devices has beneficial effects in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, it remains controversial if intravenous thrombolysis (IVT) prior to MT is superior compared to direct mechanical thrombectomy (DMT). The aims of this study were to compare short and long-term outcomes between IVT + MT and DMT patients. We prospectively recruited AIS patients with LVO in the anterior or posterior circulation eligible for MT with and without prior IVT. Modified Rankin Scale (mRS) and mortality were assessed at baseline, at discharge, 90-days and 1-year after stroke. Favorable outcome was defined as a mRS score ≤2. Of the 66 patients included, 33 (50%) were in IVT + MT group and 33 (50%) were in DMT group. Except for a higher prevalence of patients using anticoagulants at admission in DMT group, baseline characteristics did not differ in the two groups. Procedural characteristics were similar in IVT + MT and DMT group. Rate of favorable outcome was significantly higher in IVT + MT patients than DMT ones both 90-days (51.5 vs. 18.2%; p = 0.004) and 1-year (51.5 vs. 15.2%; p = 0.002) after stroke. DMT patients were six times more likely to die during the 1-year follow-up compared to IVT + MT patients. This study suggests that bridging therapy may improve short and long-term outcomes in patients eligible for endovascular treatment. Further studies with larger patient numbers and randomized design are needed to confirm our findings.

Endovascular Treatment with Intravenous Thrombolysis versus Endovascular Treatment Alone for Acute Anterior Circulation Stroke : A Meta-Analysis of Observational Studies

Objective

The aim of this study was to determine outcome of ischemic stroke patients in the anterior circulation treated with endovascular treatment (EVT) with intravenous thrombolysis (IVT) versus EVT alone group.

Methods

A systemic literature review was performed using online database from January 2004 to January 2017. Primary outcomes were successful recanalization seen on finial angiography and good outcome at three months. Secondary outcomes were mortality and the development of symptomatic intracranial hemorrhage (S-ICH) after the procedure. A fixed effect model was used when heterogeneity was less than 50%. Egger’s regression test was used to assess publication bias.

Results

Five studies were included for final analysis. Between EVT with IVT and EVT alone group, successful recanalization (odds ratio [OR] 1.467, p=0.216), good clinical outcome at three months (OR 1.199, p=0.385), mortality (OR 0.776, p=0.371), and S-ICH (OR 1.820, p=0.280) did not differ significantly. Egger’s regression intercept with 95% confidence interval (CI) was 1.99 (95% CI -2.91 to 6.89) in successful recanalization and -0.27 (95% CI -6.35 to 5.80) in good clinical outcome, respectively.

Conclusion

The two treatment modalities, EVT with IVT and EVT alone, could be comparable in treating acute anterior circulation stroke. Studies to find specific beneficiary group for EVT alone, without primary IVT, are needed further.

Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion

OBJECTIVE

In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients.

METHODS

Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0-2 at 3 months], favorable functional outcome [mRS of 0-1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed.

RESULTS

A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02-2.99) and functional improvement (common OR 1.64; 95% CI 1.05-2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26-0.96).

CONCLUSIONS

This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.

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

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.

Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center

The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.

Direct Mechanical Intervention Versus Bridging Therapy in Stroke Patients Eligible for Intravenous Thrombolysis: A Pooled Analysis of 2 Registries

BACKGROUND AND PURPOSE

Randomized controlled trials have shown that mechanical thrombectomy (MT) plus best medical treatment improves outcome in stroke patients with large-vessel occlusion in the anterior circulation. Whether direct MT is equally effective as bridging thrombolysis (intravenous thrombolysis plus MT) in intravenous thrombolysis eligible patients remains unclear.

METHODS

We compared clinical and radiological outcomes at 3 months in 249 bridging patients with 111 patients receiving direct MT for large-vessel occlusion anterior circulation stroke from 2 prospective registries (study period Essen: June 2012 to August 2013, Bern February 2009 to August 2014). We matched all patients from the direct MT group who would have qualified for intravenous thrombolysis with controls from the bridging group, using multivariate and propensity score methods. Subgroup analyses for internal carotid artery occlusions were performed.

RESULTS

Baseline characteristics did not differ between the direct MT group and bridging cohort, except for higher rates of coronary heart disease (P=0.029) and shorter intervals from onset to endovascular therapy (P<0.001) in the MT group. Functional outcome, mortality, and intracerebral hemorrhage did not differ, neither in univariate nor after multivariate and propensity score matching. However, in patients with internal carotid artery occlusion, mortality in the direct cohort was significantly lower.

CONCLUSIONS

In this matched-pair analysis, there was no difference in outcome in patients with large-vessel occlusion anterior circulation stroke treated with direct MT compared with those treated with bridging thrombolysis; however, mortality in patients with internal carotid artery occlusion treated with direct MT was significantly lower than after bridging thrombolysis. Randomized trials comparing direct MT with bridging therapy are needed.