Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry

Abstract

Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone.Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days.Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, −0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate −0.350, 95% CI, −0.680; −0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI −0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864).Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.

Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy

“…To the best of our knowledge, besides the CHOICE trial addressing an additional intra-arterial approach, there are no published data available investigating the problem we focused on in the actual study. One recent publication, also from the GSR investigators, found a better outcome in patients with inhouse bridging lysis (which should in many cases be overlapping to MT) compared to patients without lysis therapy [23,24]. But, although these data might also support the notion of the safety of concomitant lysis, their work does not address the same topic, as they compared K lysis vs. non-lysis patients and not unmitigated active lysis vs. previously iv-treated patients.…”

Safety and Efficacy of Intravenous Alteplase before Endovascular Thrombectomy: A Pooled Analysis with Focus on the Elderly

“…This finding demonstrates the low yield of IVT as a stand-alone therapy in LVO and points to a need for re-evaluation of the common "drip and ship" algorithm for LVO patients in centers not equipped for endovascular therapy rather than direct transfer to thrombectomy-capable centers. Advantages of IVT bridging may include higher EVT reperfusion rates and decrease rates of procedure-related remote emboli [20]. However, the similar rates of successful reperfusion, first-pass recanalization, and number of passes for recanalization found in our cohort suggest that IVT had no significant impact on the EVT procedure in our patients.…”

“…A total of 101 patients ≥80 years of age (mean 85.8 ± 4.5 years, 27% males) were included in the study (Table 2). Compared with patients <80 years of age, they had a higher baseline mRS (1 [0-3] vs. 0 [0], p < 0.001), admission NIHSS (19 [14][15][16][17][18][19][20][21][22] vs. 15 [10][11][12][13][14][15][16][17][18][19][20], p < 0.001), and mRS 90 (2 [1][2][3][4] vs. 4 [3][4][5][6], p < 0.001), and lower rates of favorable outcome (28% vs. 53%, p < 0.001) (Supplemental Table S1). Patients above 80 years of age also had higher rates of hypertension and atrial fibrillation and lower rates of smoking (82% vs. 61%, p < 0.001, 49% vs. 31%, p = 0.03, 13% vs. 34%, p < 0.001, respectively).…”

Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe

“…When this question is analyzed in real-world studies, the balance tips toward a greater benefit of BT treatment regarding the 90-day functional outcome [ 5 , 26 , 27 , 28 , 29 , 30 , 31 ], although some heterogeneity persists with some authors reporting no significant differences between the two groups [ 32 , 33 ].…”