Endovascular thrombectomy in anterior circulation stroke and clinical value of bridging with intravenous thrombolysis

Abstract

Background Bridging treatment with intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in acute ischemic stroke is applied under the assumption of benefits for patients with large vessel occlusion (LVO). However, the benefit of this additional step has not yet been proven. Purpose To compare procedural parameters (procedural time, number of attempts), complications, and clinical outcome in patients receiving EVT vs. patients with bridging treatment. Material and Methods In this prospective study all patients had acute anterior cerebral circulation occlusion and were treated with EVT. All patients were selected for treatment based on clinical criteria, multimodal computed tomography (CT) imaging. Eighty-four patients were treated with bridging IVT followed by EVT; 62 patients were treated with EVT only. Results Bridging therapy did not influence endovascular procedure time ( P = 0.71) or number of attempts needed ( P = 0.63). Bleeding from any site was more common in the bridging group (27, 32%) vs. the EVT group (12, 19%) ( P = 0.09). Functional independence modified Rankin Scale after 90 days was slightly higher in the bridging group (44%) vs. the EVT group (42%) ( P = 0.14). Mortality did not differ significantly at 90 days: 17% in the bridging group vs. 21% in EVT alone ( P = 0.57). Both treatment methods showed high recanalization rates: 94% in the bridging group and 89% for EVT alone. Conclusion Bridging treatment in LVO did not show benefits or elevated risks of complications in comparison to EVT only. The bridging group did not show significantly better neurological outcome or significant impact on procedural parameters vs. EVT alone.

Repeated mechanical thrombectomy for acute ischemic stroke in a dialysis patient: A case report and literature review

“…17 The Japanese guidelines state that stroke patients with severe renal disorder should be given IVT cautiously. 20 In our patient's case, the clinical presentation suggested LVO, and waiting for the coagulation test results would have delayed the patient's treatment; therefore, we bypassed IVT and went directly to MT. There is no need to wait for renal function test results before IVT.…”

“…A study showed that the prognosis after direct MT in patients with LVO is not inferior to that of patients who received IVT as bridging therapy before MT. 20 In our patient's case, the clinical presentation suggested LVO, and waiting for the coagulation test results would have delayed the patient's treatment; therefore, we bypassed IVT and went directly to MT. In general, IVT is not a contraindication for patients with renal insufficiency in AIS.…”

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

“…Many studies, in fact, did not reveal any difference between the two treatments. [14][15][16][17][18][19][20][21][22] On the whole the available studies are based on small samples of patients, the larger study being the Catalonia analysis, including 1166 patients. 18 On the basis of data from a recent meta-analysis, 26 assuming an alpha of 0.05 and beta of 0.2, a total sample of 408 patients would be needed to detect a 12% absolute difference in 90-day death or severe dependency, and 962 patients to detect a 9.7% absolute difference in functional independence at three months.…”

“…Observational retrospective analyses gave conflicting results: while some of them suggested a benefit of IVT pretreatment, [9][10][11][12][13] in terms of higher rate of recanalization, shorter duration of the endovascular procedure, lower number of passes of the thrombectomy device per patient, or better clinical outcome, others did not find significant differences between the two approaches. [14][15][16][17][18][19][20][21][22] A pooled analysis 23 of the STAR 24 and SWIFT 25 trials suggested that treatment with IVT before MT does not add any clinical benefit as compared to MT alone. Conversely, two meta-analyses carried out on subgroups of patients included in the available randomized clinical trials, 26 and on available observational and randomized studies 27 showed that bridging therapy leads to a lower probability of death or serious disability as compared to MT alone.…”

“…Observational retrospective analyses gave conflicting results: while some of them suggested a benefit of IVT pretreatment, 9–13 in terms of higher rate of recanalization, shorter duration of the endovascular procedure, lower number of passes of the thrombectomy device per patient, or better clinical outcome, others did not find significant differences between the two approaches. 14–22…”