Intraarterial thrombolytics as an adjunct to mechanical thrombectomy in patients with basilar artery occlusion

Abstract

Background and Purpose There are limited data regarding safety and effectiveness of concurrent intraarterial thrombolytics as adjunct to mechanical thrombectomy in acute ischemic stroke patients with basilar artery occlusion. Methods We analyzed data from a prospective multicenter registry to assess the independent effect of intraarterial thrombolysis on (1) favorable outcome (modified Rankin Scale 0‐3) at 90 days; (2) symptomatic intracranial hemorrhage (sICH) within 72 hours; and (3) death within 90 days post‐enrollment after adjustment for potential confounders. Results There was no difference in the adjusted odds of achieving favorable outcome at 90 days (odds ratio [OR] = 1.1, 95% confidence interval [CI]: 0.73‐1.68) in patients who received intraarterial thrombolysis (n = 126) compared with those who did not receive intraarterial thrombolysis (n = 1546) despite significantly higher use in patients with postprocedure modified Thrombolysis in Cerebral Infarction (mTICI) grade <3. There were no differences in adjusted odds of sICH within 72 hours (OR = 0.8, 95% CI: 0.31‐2.08) or death within 90 days (OR = 0.91, 95% CI: 0.60‐1.37). In subgroup analyses, intraarterial thrombolysis was associated with (nonsignificantly) higher odds of achieving a favorable outcome at 90 days among patients aged between 65 and 80 years, those with National Institutes of Health Stroke Scale score <10, and those with postprocedure mTICI grade 2b. Conclusions Our analysis supported the safety of intraarterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients with basilar artery occlusion. Identification of patient subgroups in whom intraarterial thrombolytics appeared to be more beneficial may assist in future clinical trial designs.

Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis

“…A previous meta-analysis including 4581 patients by Chen et al 10 reported that IA treatment (thrombolytics or glycoprotein IIb/IIIa inhibitors) was associated with a higher rate of functional independence and another meta-analysis including 2797 patients by Kaesmacher et al 11 reported that IAT was not associated with higher rates of functional independence as an adjunct to MT. Inclusion of additional studies 5,[12][13][14][15][16][17] such as results from the randomized CHOICE 17 trial in our analysis increased the sample size (7572 patients) by almost 2-4 folds compared with the previous analyses by Chen et al 10 and Kaesmacher et al 11 Therefore, the precision of estimates of various outcomes was higher, and type 2 errors in comparisons were reduced. By increasing the design diversity among included studies, we also identified the prominent effect of design and quality of the studies on the association between IAT and functional independence at 90 days.…”

“…The quality of included observational studies 5,6,[12][13][14][15][16][20][21][22][25][26][27][28][29][30][31] was assessed by three independent reviewers (A.L., I.N.A., and D.K.) for risk of bias using the Newcastle-Ottawa Quality Scale (NOS) for Cohort Studies.…”

“…The median quality grade was 8, with 11 studies having a quality grade of 8 or greater for risk of bias using the NOS scoring system 5,6,[12][13][14][15][16]20,25,29,31 (see Supplemental Tables 3 and 4). There was an overall low risk of bias using Rob-2 assessment tool for the randomized controlled trial.…”

“…[7][8][9] There are two previous systematic reviews and meta-analyses by Chen et al 10 and Kaesmacher et al, 11 which have provided conflicting results. A more conclusive analysis may be possible with the availability of additional studies 5,[12][13][14][15][16][17] including results from the randomized Chemical Optimization of Cerebral Embolectomy (CHOICE) 17 clinical trial. We performed an updated systematic review of the literature to evaluate the effect of IAT as an adjunct to MT.…”