Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

Real-world setting comparison of bridging therapy versus direct mechanical thrombectomy for acute ischemic stroke: A meta-analysis

BACKGROUND AND PURPOSE

Intravenous Thrombolysis (IVT) prior to Mechanical Thrombectomy (MT) for Acute Ischaemic Stroke (AIS) due to Large-Vessel Occlusion (LVO) remains controversial. Therefore, the authors performed a meta-analysis of the available real-world evidence focusing on the efficacy and safety of Bridging Therapy (BT) compared with direct MT in patients with AIS due to LVO.

METHODS

Four databases were searched until 01 February 2023. Retrospective and prospective studies from nationwide or health organization registry databases that compared the clinical outcomes of BT and direct MT were included. Odds Ratios (ORs) and 95 % Confidence Intervals (CIs) for efficacy and safety outcomes were pooled using a random-effects model.

RESULTS

Of the 12 studies, 86,695 patients were included. In patients with AIS due to LVO, BT group was associated with higher odds of achieving excellent functional outcome (modified Rankin Scale score 0-1) at 90 days (OR = 1.48, 95 % CI 1.25-1.75), favorable discharge disposition (to the home with or without services) (OR = 1.33, 95 % CI 1.29-1.38), and decreased mortality at 90 days (OR = 0.62, 95 % CI 0.56-0.70), as compared with the direct MT group. In addition, the risk of symptomatic intracranial hemorrhage did not increase significantly in the BT group.

CONCLUSION

The present meta-analysis indicates that BT was associated with favorable outcomes in patients with AIS due to LVO. These findings support the current practice in a real-world setting and strengthen their validity. For patients eligible for both IVT and MT, BT remains the standard treatment until more data are available.

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.

Deep Learning-Based Computed Tomography Perfusion Imaging to Evaluate the Effectiveness and Safety of Thrombolytic Therapy for Cerebral Infarct with Unknown Time of Onset

This study was aimed to discuss the effectiveness and safety of deep learning-based computed tomography perfusion (CTP) imaging in the thrombolytic therapy for acute cerebral infarct with unknown time of onset. A total of 100 patients with acute cerebral infarct with unknown time of onset were selected as the research objects. All patients received thrombolytic therapy. According to different image processing methods, they were divided into the algorithm group (artificial intelligence algorithm-based image processing group) and the control group (conventional method-based image processing group). After that, the evaluations of effectiveness and safety of thrombolytic therapy for the patients with acute cerebral infarct in the two groups were compared. The research results demonstrated that artificial intelligence algorithm-based CTP imaging showed significant diagnostic effects and the image quality in the algorithm group was remarkably higher than that in the control group (P < 0.05). Besides, the overall image quality of algorithm group was relatively higher. The differences in the National Institute of Health stroke scale (NIHSS) scores for the two groups indicated that the thrombolytic effect on the algorithm group was superior to that on the control group. Thrombolytic therapy for the algorithm group showed therapeutic effects on neurologic impairment. The symptomatic intracranial hemorrhage rate of the algorithm group within 24 hours was lower than the hemorrhage conversion rate of the control group, and the difference between the two groups was 14%. The data differences between the two groups showed statistical significance (P < 0.05). The results demonstrated that the safety of guided thrombolytic therapy for the algorithm group was higher than that in the control group. To sum up, deep learning-based CTP images showed the clinical application values in the diagnosis of cerebral infarct.

Bridging Thrombolysis Achieved Better Outcomes Than Direct Thrombectomy After Large Vessel Occlusion: An Updated Meta-Analysis

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.

Long-Term Outcomes in Patients with Stroke after in-Hospital Treatment-Study Protocol of the Prospective Stroke Cohort Augsburg (SCHANA Study)

INTRODUCTION

In Germany, stroke is the third leading cause of death, with more than 60,000 fatalities out of approximately 260,000 cases (first-ever and recurrent strokes) each year. So far, there are only a few long-term studies investigating determinants of the natural course of the disease, especially in the era of mechanical thrombectomy.

MATERIALS AND METHODS

The prospective single-center stroke cohort Augsburg (SCHANA) study will include about 1000 patients treated for stroke in the University Hospital of Augsburg. Patients aged 18 years or older with a confirmed diagnosis of ischemic or hemorrhagic stroke are included in the study. Information on demographic characteristics, onset of symptoms, etiologic factors, comorbidities, quality of life, invasive and non-invasive treatment, complications, and laboratory parameters are collected during a personal interview conducted during the patients' hospital stay and via a medical chart review. About 30 mL of blood is collected from each patient, and after processing and aliquoting, all blood specimens are frozen at -80° C. The study participants will be followed-up via postal questionnaires at three and 12 months after discharge from the hospital. Furthermore, mortality follow-ups will be conducted. Cox-regression analysis will be used to estimate relative risks.

CONCLUSION

The SCHANA study will generate comprehensive data on the long-term course of the disease. In addition to the main outcomes, recurrent events and survival, patient-oriented outcomes such as health-related quality of life and depression are the focus of the study.

Effect of time from onset to endovascular therapy on outcomes: the National Acute Stroke Israeli (NASIS)-REVASC registry

Background

Endovascular therapy (EVT) is currently the most effective treatment for emergent large vessel occlusion (ELVO) stroke. Earlier treatment is associated with a better clinical outcome. Our aim was to examine the association between onset-to-EVT (OTE) time and clinical outcomes using real-world nationwide data from the National Acute Stroke ISraeli (NASIS)-REVASC registry.

Methods

Stroke patients undergoing EVT within the Endovascular Capable Centres (ECCs) in Israel between January 2014 and March 2016 were prospectively included. Several clinical and radiological outcomes were evaluated. The association between OTE time and outcomes was analyzed with logistic regression models using time as a continuous variable and then by OTE groups of <2, 2–4, 4–6, and >6 hours.

Results

299 patients with acute stroke were included in the analysis. OTE time was significantly associated with favorable outcomes. ORs for each hour of delay in EVT were 0.84 (95% CI 0.71 to 0.99) for significant early recovery, 0.80 (95% CI 0.68 to 0.94) for discharge to home, 0.80 (95% CI 0.66 to 0.95) for freedom from disability at discharge, and 0.78 (95% CI 0.67 to 0.91) for excellent reperfusion (Thrombolysis in Cerebral Ischemia 3). The <2 OTE group was significantly associated with better outcomes than the ≥2 OTE group including significant early recovery (OR 3.3, 95% CI 1.2 to 9.1), discharge to home (OR 3.32, 95% CI 1.3 to 8.5), and excellent reperfusion (OR 4.6, 95% CI 1.3 to 29.5). The same trend was observed for freedom from disability at discharge and 3 months (OR 2.08, 95% CI 0.7 to 5.7 and OR 2.57, 95% CI 0.8 to 8.3, respectively). Only 1% of transferred patients achieved an OTE time of <2 hours.

Conclusions

Nationwide real-life registry data indicate that benefit from EVT is strongly associated with OTE time and is most prominent within the ‘two golden hours’ from stroke onset. This time goal may not be applicable in inter-hospital transfer patients.