Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Abstract

Background: The current guideline recommends using an intravenous tissue-type plasminogen activator (IV tPA) prior to mechanical thrombectomy (MT) in eligible acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). Some recent studies found no significant differences in the long-term functional outcomes between bridging therapy (BT, i.e., IV tPA prior to MT) and direct MT (dMT). Methods: We conducted a systematic review and meta-analysis to compare the safety and functional outcomes between BT and dMT in AIS patients with ELVO who were eligible for IV tPA administration. Based on the ELVO location, patients were categorized as the anterior group (occlusion of the anterior circulation), or the combined group (occlusion of the anterior and/or posterior circulation). A subgroup analysis was performed based on the study type, i.e., RCT and non-RCT. Results: Thirteen studies (3985 patients) matched the eligibility criteria. Comparing the BT and dMT groups, no significant differences in terms of mortality and good functional outcome were observed at 90 days. Symptomatic intracranial hemorrhagic (sICH) events were more frequent in BT patients in the combined group (OR = 0.73, p = 0.02); this result remained significant only in the non-RCT subgroup (OR = 0.67, p = 0.03). The RCT subgroup had a significantly higher rate of successful revascularization in BT patients (OR = 0.73, p = 0.02). Conclusions: Our meta-analysis uncovered no significant differences in functional outcome and mortality rate at 90 days between dMT and BT in patients with AIS who had ELVO. Although BT performed better in terms of successful recanalization rate, there is a risk of increased sICH rate in this group.

Direct mechanical thrombectomy versus bridging therapy in acute ischemic stroke: A systematic review and meta-analysis of randomized clinical trials

“… 32 Kolahchi et al , when analyzing 4 RCTs and 9 observational studies, found no differences regarding functional independence and mortality, but reported higher rates of sICH in the BT group (OR 0.73; 95 % CI, 0.56–0.96, p = 0.02, I 2 = 0 %), a result that remained significant only in the observational studies group after subgroup analysis; likewise, successful reperfusion rate was higher for BT in the RCTs subgroup (OR 0.73; 95 % CI, 0.56–0.96, p = 0.02, I 2 = 0 %).). 22 The overall results of this study differ from ours in the pooled analysis; however, the RCTs subgroup analysis is consistent with ours. We believe that the main limitation of these publications is that they have a high risk of bias due to the combination of different methodological designs and analysis, which would explain their high heterogeneity; 33 therefore, it is more appropriate to use data provided only from randomized clinical trials to guide clinical practice on the topic.…”

“…Recent clinical trials, observational studies, as well as pooled data and meta-analyses, suggest that direct mechanical thrombectomy (dMT) could be as effective as bridging therapy (BT), obtaining good functional results on its own. 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 In clinical practice, IVT prior to MT (BT) has potential benefits and risks. Although some studies suggested that IVT may increase the perfusion of large occluded vessels and improve the general outcome, the recanalization rate is relatively low, especially in proximal vessel occlusions.…”

“…Although some studies suggested that IVT may increase the perfusion of large occluded vessels and improve the general outcome, the recanalization rate is relatively low, especially in proximal vessel occlusions. 23 , 24 Moreover, it can potentially increase the risk of intracranial bleeding (ICH), 12 , 22 , 25 lead to clot fragmentation and migration, as well as complicating the patient management algorithm, particularly in centers where the “drip and ship” protocol is applied, causing delays in the initiation of MT. 26 , 27 …”

“… 28 , 29 However, other authors differ as they have not found significant differences between the two groups, although they do report differences in reperfusion rates and risk of intracranial hemorrhage, favoring dMT. 20 , 22 , 30 Results between studies differ widely, so the debate continues.…”

Expert Consensus on Improving Stroke Care Ecosystem in India

“…A recent systematic review and meta-analysis comparing BT and direct MT for AIS with LVO found no significant difference in mortality and functional outcome after 90 days. 95 As per Indian guidelines, AIS patients with LVO may be considered for bridging IV thrombolysis (alteplase 0.9 mg/kg infusion or Tenecteplase 0.2-0.25 mg/kg bolus) followed by MT. 96 In India, MT costs approximately 400,000-500,000 INR.…”