Endovascular Treatment in Patients with Persistent Internal Carotid Artery Occlusion after Intravenous Tissue Plasminogen Activator: A Clinical Effectiveness Study

Abstract

Background: There has been no large-scale trial comparing endovascular treatment (add-on EVT) after intravenous tissue plasminogen activator (IV tPA) and IV tPA alone in acute ischemic stroke (AIS) caused by internal carotid artery occlusion (ICAO). We aimed at investigating the effectiveness and safety of add-on EVT after IV tPA in AIS patients with ICAO. Methods: Between March 2010 and March 2013, 3,689 consecutive ischemic stroke patients who were hospitalized within 4.5 h of onset were identified using a prospective stroke registry at 11 centers in Korea. Among them, patients with persistent ICAO after receiving IV tPA and whose 3-month modified Rankin Scale (mRS) was available were finally enrolled. A propensity score analysis with inverse-probability of treatment weighting was used to eliminate baseline imbalances between those receiving add-on EVT and IV tPA alone. Results: Among 264 patients enrolled in this study (mean age 71.4; male 56.4%; median National Institute of Health Stroke Scale score 15), 117 (44.3%) received add-on EVT. The add-on EVT group had a higher frequency of favorable outcome on the mRS ≤2 (35.0 vs. 18.4%; adjusted OR (aOR) 2.79; 95% CI 1.66-4.67) and lower mortality (17.9 vs. 35.4%; aOR 0.24; 95% CI 0.13-0.42) at 3 months, when compared to the IV tPA-alone group. Add-on EVT did not significantly increase the risk of symptomatic hemorrhage (5.1 vs. 4.1%; aOR 1.01; 95% CI 0.37-2.70). The rate of successful recanalization (thrombolysis in cerebral infarction grade ≥2b) in the add-on EVT group was 69.2%. Conclusions: Compared to an IV tPA alone, add-on EVT can improve clinical outcomes in patients with symptomatic ICAO within 4.5 h of onset without a significant increase of symptomatic hemorrhage.

Collateral grade of the Willis' circle predicts outcomes of acute intracranial internal carotid artery occlusion before thrombectomy

“…A rate of favorable outcomes of 32.6%–60% was achieved in the intervention group of the MR CLEAN trial (Berkhemer et al, ) and the SWIFT PRIME trial (Saver et al, ). However, different the rate of favorable outcomes varying from 28% to 60% (Fockaert et al, ; Hong et al, ; Kim, Kang, Hwang, Park, & Kim, ; Kwak et al, ) were reported, suggesting that a substantial proportion had not recovered independence by 90 days after onset. Several factors, including National Institutes of Health Stroke scale (NIHSS) onset, occlusion type and occlusion level, have been reported to be associated with favorable functional outcomes, while others, such as poor initial status, unsuccessful recanalization, cardioembolism, and supraclinoid‐terminal occlusion, are associated with poor outcomes of AIS with internal carotid artery occlusion (Kwak et al, ).…”

Endovascular Therapy for Tandem Occlusion in Acute Ischemic Stroke: Intravenous Thrombolysis Improves Outcomes

“…A study investigating outcomes after thrombolysis alone compared to thrombolysis with add-on EVT during the first 4.5 hours after stroke demonstrated more favorable outcomes with the latter approach in terms of mRS (0–2) at three months (35.0 vs. 18.4%; adjusted OR (aOR) 2.79; 95% CI 1.66–4.67) and mortality rates (17.9 vs. 35.4%; aOR 0.24; 95% CI 0.13–0.42) [16]. Our patients treated with t-PA and EVT had a better chance of favorable outcome, comparable with a previous report [11].…”

“…EVT using intracranial stent retrieval-assisted thrombectomy can be combined with extracranial stenting/dilatation in cases of TIM occlusion, where t-PA treatment alone would achieve recanalization in only 9% of patients [13,14]. Previous studies consistently demonstrated favorable outcomes defined as modified Rankin Score (mRS) of 0–2 in 28–35% of patients receiving EVT [15,16]. There may also be an increased risk of intracranial hemorrhage with the administration of combined antithrombotic medications after acute stenting in the setting of TIM occlusion [17].…”

Curative effect of minimally invasive puncture and drainage assisted with alteplase on treatment of acute intracerebral hemorrhage

“…Alteplase is an emerging new-type hematoma dissolving drug in recent years, also a plasminogen activator compounded by using genetic engineering technology, which has a high selectivity of fibrous protein. It will not cause hyperfibrinolysis when dissolving hematoma [15][16][17]. We can see by analyzing the evacuation of hematoma with two assistant hematoma dissolving drugs in the treatment of acute intracerebral hemorrhage, that the volumes of hematoma and edema, the midline shift distance and incidence rate of rebleeding from alteplase group were significantly lower than those of urokinase group, which indicated that as for the effect on evacuation of hematoma, adjuvant therapy with alteplase was superior to that with urokinase, and the recurrence risk of Table 1 The evacuation of hematoma of the two groups.…”