Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

Abstract

Background It is unclear whether intravenous thrombolysis ( IVT ) with alteplase before endovascular treatment ( EVT ) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results Using multivariable regression, we evaluated the association of IVT + EVT with 90‐day functional outcome (modified Rankin Scale), mortality, reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT + EVT , and 324 (22%) with EVT alone. Patients treated with IVT + EVT had atrial fibrillation less often (16% versus 44%) and had better pre‐stroke modified Rankin Scale scores (pre‐stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT + EVT group (median 62 versus 68 minutes). Nontransferred IVT + EVT patients had longer door‐to‐groin‐puncture times (median 105 versus 94 minutes). IVT + EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI : 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI : 0.40–0.82). Successful reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions In this observational study, patients treated with IVT + EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT , but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT .

Intravenous Thrombolysis Is Not Associated with Increased Time to Endovascular Treatment

“…Previous results from a smaller and earlier sample set of the MR CLEAN Registry demonstrated a slightly longer door to groin time in directly referred patients treated with IVT, while we found a shorter door to groin time in these patients [8]. They did not look at functional and safety outcomes in directly referred patients separately but did demonstrate a higher odds of a favorable shift on the mRS for all (directly referred and transferred) IVT treated patients.…”

“…Patient data were retrospectively analyzed from March 16, 2014, up to November 1, 2017. Recent results from an earlier part of this dataset containing data up to June 2016 analyzed clinical outcomes and some workflow outcomes [8]. This current analysis differs in the use of a larger dataset and inclusion of more detailed workflow intervals.…”

“…Adjusted door to CT imaging and door to groin time were shorter in IVT + EVT patients (difference 5.7 min [95% CI: 4.6-6.8] and 7.0 min [95% CI: 2. [4][5][6][7][8][9][10][11][12], respectively) while CT imaging to groin time was similar between the groups. Early recanalization on digital subtraction angiogra phy before EVT was seen more often after prior IVT (11 vs. 5.2%,).…”

Reperfusion strategies in stroke due to isolated cervical internal carotid artery occlusion: systematic review and treatment comparison

“…Our results add to the available literature and refine findings from previous reports on reperfusion strategies in large vessel occlusion. Higher rates of reperfusion and improvement in functional outcome have been reported with bridging treatment compared to IVT alone [6,[14][15][16][17][18]. However, there is still vast debate on the role of IVT before EVT on large vessel occlusion, with a reverberating hypothesis of a potential hazard with IVT as opposed to a 10% chance of recanalization with IVT only [6,19].…”

Stroke Treatment Delay Limits Outcome After Mechanical Thrombectomy: Stratification by Arrival Time and ASPECTS

“…In patients with acute ischemic stroke, the presence of a proximal large vessel occlusion (LVO) is associated with a poor outcome and emergent mechanical thrombectomy (MT) with or without alteplase is associated with a significant improvement in functional outcome 1‐5 . However, past investigations have emphasized the importance of rapid reperfusion, with each 15‐minute incremental delay associated with a 10% decrease in the likelihood of good outcome 6 …”