Comparison of Partial (.6 mg/kg) versus Full-Dose (.9 mg/kg) Intravenous Recombinant Tissue Plasminogen Activator Followed by Endovascular Treatment for Acute Ischemic Stroke: A Meta-Analysis

Abstract

In the treatment of acute ischemic stroke, intravenous (IV) recombinant tissue plasminogen (rt-PA) and intraarterial (IA) interventions are often combined. However, the optimal dose of IV rt-PA preceding endovascular treatment has not been established. METHODSStudies that used combined IV and IA thrombolysis were identified from a search of the MEDLINE, PubMed, and Cochrane databases. We compared the rates of angiographic recanalization, symptomatic intracerebral hemorrhage (sICH), and favorable functional outcome between patients who had been treated with .6 mg/kg IV rt-PA and those who had received .9 mg/kg rt-PA. RESULTSEleven studies met our criteria. In 7 studies, .6 mg/kg IV rt-PA had been administered to 317 patients, whereas 140 patients in 4 studies had received .9 mg/kg of IV rt-PA. The weighted mean of median National Institutes of Health Stroke Scale score at presentation was 18.3 in the .6 mg/kg group (median range 9-34), and 17.3 in the .9 mg/kg group (median range 4-39). Patients in the .9 mg/kg group had higher rates of favorable outcome [odds ratio (OR) = 1.60, 95% confidence interval (CI) = (1.07-2.40), P = .022] and similar rates of sICH [OR = .86 (95% CI .41-1.83), P = .70]. Depending on the statistics used, the higher angiographic recanalization rate among patients treated with .9 mg/kg was significant (P = .03, events/trial syntax logistic regression) or borderline significant (P = .07, random effects model). CONCLUSIONOur analysis suggests that using .9 mg/kg IV rt-PA prior to IA thrombolysis is safe and may be associated with higher recanalization rates and better functional outcome at 3 months.

Safety of High Doses of Urokinase and Reteplase for Acute Ischemic Stroke

“…A recent metaanalysis concluded that prior full-dose IVT is superior to lowdose IVT in achieving higher recanalization rates and better outcomes when combined with ET. 9 In a small case series, IA thrombolysis with RT demonstrated a trend toward higher rates of recanalization and SICH without prior IVT compared with IA UK. 10 The safety, however, of using high IA doses of thrombolytic agents when used with multimodal ET is unclear.…”

The safety and efficacy of bridging full-dose IV-IA thrombolysis in acute ischemic stroke patients with MCA occlusion: A comparison with IV thrombolysis alone

“…A recently reported metaanalysis, which compared low-dose (0.6 mg/kg) and full-dose (0.9 mg/kg) rt-PA followed by IAT, suggested that using full-dose IV rt-PA prior IAT is safe and might be associated with higher recanalization rates and better functional outcome at 3 months than using of low-dosed rt-PA (ref. 24 ). Our study has some limitations.…”

Management of acute basilar artery occlusion: Should any treatment strategy prevail?

“…39,54,55 ) or glycoprotein IIb/IIIa inhibitors abciximab and tirofiban, with a high recanalization rate of endovascular techniques 14,24,44,46 . Despite published data from 2 meta-analyses supporting bridging therapy as a therapeutic approach in patients with large vessel occlusion 56,57 recent studies report no significant difference in functional outcome between bridging and IVT alone and endovascular treatment alone 58,59 . Georgiadis et al compared IVT vs. combination of IV and IA thrombolysis in his meta-analysis comprising 11 studies with a total of 457 patients 57 .…”

“…Despite published data from 2 meta-analyses supporting bridging therapy as a therapeutic approach in patients with large vessel occlusion 56,57 recent studies report no significant difference in functional outcome between bridging and IVT alone and endovascular treatment alone 58,59 . Georgiadis et al compared IVT vs. combination of IV and IA thrombolysis in his meta-analysis comprising 11 studies with a total of 457 patients 57 . One hundred and forty patients in 4 studies received 0.9 mg/kg of IV rt-PA while 317 patients in 7 studies received 0.6 mg/kg.…”