Intravenous thrombolysis before mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion; should we cross that bridge? A systematic review and meta-analysis of 36,123 patients

Ghaith, Hazem S.; Elfil, Mohamed; Gabra, Mohamed Diaa; Nawar, Asmaa Ahmed; Abd-Alkhaleq, Mohamed Sameh; Hamam, Khaled M.; Aboelnasr, Lara Ebrahim; Elgezery, Esraa Ayman; Elsayed, Hanaa; Swed, Sarya; Kanmounye, Ulrick Sidney; Negida, Ahmed

doi:10.1007/s10072-022-06283-6

Cited by 16 publications

(5 citation statements)

References 66 publications

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“…This difference may be explained considering the improvement of long-term functional outcomes of ischemic stroke over the last five years due to intravenous thrombolysis and endovascular treatments for large vessel occlusion. 30 …”

Section: Discussionmentioning

confidence: 99%

When the practice does not meet the theory: results from an Italian survey on the clinical and pathway management of inpatients with decompressive craniectomy or cranioplasty admitted to rehabilitation

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Formisano

Iaccarino

et al. 2023

Eur J Phys Rehabil Med

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BACKGROUND Cranioplasty (CP) is supposed to improve the functional outcome of severe acquired brain injury (sABI) patients with decompressive craniectomy (DC). However, ongoing controversies exist regarding its indications, optimum materials, timing, complications, and relationships with hydrocephalus (HC). For these reasons, an International Consensus Conference (ICC) on CP in traumatic brain injury (TBI) was held in June 2018 to issue some recommendations. AIM The aims of this study were: to investigate cross-sectionally before the ICC the prevalence of DC/CP in sABI inpatients admitted to neurorehabilitation units in Italy; to assess the perception of Italian clinicians working in the sABI neurorehabilitation settings on the management of inpatients with DC/CP during their rehabilitation stay. DESIGN Cross-sectional. SETTING AND POPULATION Physiatrists or neurologists working in 38 Italian rehabilitation centers involved in the care of sABI, giving a pooled sample of 599 inpatients. METHODS Survey questionnaire consisting of 21 closed-ended questions with multiple-choice answers. Sixteen questions regarded the respondents’ opinions and experiences regarding the clinical and management aspects of patients. Survey data were collected via e-mail between April and May 2018. RESULTS About 1/3 of the 599 inpatients had either a DC (18.9%) or a CP (13.5%). TBI and cerebral hemorrhage were strongly associated with DC/CP, although the association was much stronger for TBI. Significant discrepancies were uncovered between some of the recommendations of the ICC and the corresponding perceptions of the respondents, especially regarding the clinical management of patients ( i.e. , CP timing). Clear guidelines were perceived as the most crucial factor in improving clinical pathways. CONCLUSIONS Early collaboration between the neurosurgical and the neurorehabilitation teams is crucial to optimize all clinical and organizational factors, which could expedite CP and minimize the risk of complications, such as infections and HC, to ensure the best possible outcome for DC patients, regardless of the etiology of the sABI. CLINICAL REHABILITATION IMPACT There may be different attitudes and perceptions, if not controversies, between neurorehabilitation physicians and neurosurgeons regarding the optimal clinical and care pathway management of patients with DC/CP in Italy. Therefore, an Italian Consensus Conference involving all stakeholders on the clinical and management pathways of DC/CP patients admitted to neurorehabilitation is advocated.

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Section: Discussionmentioning

confidence: 99%

When the practice does not meet the theory: results from an Italian survey on the clinical and pathway management of inpatients with decompressive craniectomy or cranioplasty admitted to rehabilitation

Porta

Formisano

Iaccarino

et al. 2023

Eur J Phys Rehabil Med

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“…In the light of inconclusive observations on the effect of bridging IVT for acLVO on functional outcome from several RCTs and meta-analyses [3][4][5][6][7][8][9]15 , recent research focused on deeper exploration of patient and treatment-related characteristics that might modulate this effect. A retrospective analysis of the International Stroke Perfusion Imaging Registry (n=323) suggested that bridging IVT (n=241) is beneficial in patients with fast growing infarct core due to more rapid completion of thrombectomy resulting in a reduced final size of the ischemic lesion.…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5][6] The latter observation was recently supported by a meta-analysis of clinical trials and observational studies that synthesized data from 36,123 patients and found slightly improved functional outcome and reperfusion rates in thrombectomy patients who also received bridging IVT. 7 Moreover, the open-label, blinded-endpoint, randomized trials SWIFT-DIRECT and DIRECT-SAFE failed to show non-inferiority of omitting bridging IVT before thrombectomy and even found effect directions in favor of bridging IVT. 8,9 Consequentially, the question whether bridging IVT adds value to thrombectomy beyond non-inferiority continues to be a topic of exploration.…”

Section: Introductionmentioning

confidence: 99%

Intravenous Thrombolysis before Thrombectomy Improves Functional Outcome after Stroke Independent of Reperfusion Grade

Sedghi,

Kaiser,

Cuberi

et al. 2023

Preprint

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Background: We studied the effect of bridging intravenous thrombolysis (IVT) before thrombectomy for anterior circulation large vessel occlusion (acLVO) on functional outcome and scrutinized its dependence on grade of reperfusion and distal thrombus migration. Methods: We included consecutive acLVO patients from our prospective registry of thrombectomy-eligible patients treated from 01/01/2017 to 01/01/2023 at a tertiary stroke center in Germany into a retrospective cohort study. We evaluated the effects of bridging IVT on functional outcome quantified via modified Rankin scale (mRS) at 90 days applying multivariable logistic and lasso regression including interaction terms with grade of reperfusion quantified via modified Thrombolysis in Cerebral Infarction (mTICI) scale and distal thrombus migration adjusted for demographic and cardiovascular risk profiles, clinical and imaging stroke characteristics, onset-to-recanalization time and distal thrombus migration. We performed sensitivity analysis using propensity score matching. Results: In our study population of 1000 thrombectomy-eligible patients (513 females, median age 77 [67-84, interquartile range]) IVT emerged as predictor of favorable functional outcome (mRS 0-2) independent of mTICI (adjusted OR 0.49; 95% CI [0.32;0.75]; p=0.001). In those who underwent thrombectomy (n=812) the association of IVT and favorable functional outcome was reproduced (adjusted OR 0.49; 95% CI [0.31;0.74]; p=0.001) and was further confirmed on propensity score analysis where IVT led to a 0.35-point decrease in 90-day mRS score [ß=-0.35; 95CI% [-0.68;-0.01]; p=0.04]. The additive benefit of IVT remained independent of mTICI (ß=-1.79; 95% CI [-3.43;-0.15]; p=0.03) and distal thrombus migration (ß=-0.41; 95% CI [-0.69;-0.13]; p=0.004) on interaction analysis. Consequently, IVT showed an additive effect on functional outcome in the subpopulation of thrombectomy patients who achieved successful reperfusion (TICI?2b; ß=-0.46; 95% CI [-0.74;-0.17]; p=0.002) and remained beneficial in those with unsuccessful reperfusion (TICI?2a; ß=-0.47; 95% CI [-0.96;-0.01]; p=0.05). Conclusions: In thrombectomy-eligible acLVO patients IVT improves functional outcome independent of grade of reperfusion and distal thrombus migration.

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“…Current IS treatment relies entirely on reperfusion therapy, including thrombolysis and thrombectomy. Thrombolysis is mainly administered with recombinant tissue plasminogen activator (rt-PA) or other proteins with similar activity ( Crocker et al, 2021 ; Faizy et al, 2022 ), whereas thrombectomy is primarily endovascular treatment (EVT) and mechanical thrombectomy ( Herpich and Rincon, 2020 ; Ghaith et al, 2022 ). However, due to the highly limited time window and the risk of hemorrhagic events, t-PA can only be used in less than 10% of patients with stroke and with less than 50% achieving success ( Rha and Saver, 2007 ; Peña-Martínez et al, 2022 ).…”

Section: Introductionmentioning

confidence: 99%

The role of circadian clock in astrocytes: From cellular functions to ischemic stroke therapeutic targets

et al. 2022

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Accumulating evidence suggests that astrocytes, the abundant cell type in the central nervous system (CNS), play a critical role in maintaining the immune response after cerebral infarction, regulating the blood-brain barrier (BBB), providing nutrients to the neurons, and reuptake of glutamate. The circadian clock is an endogenous timing system that controls and optimizes biological processes. The central circadian clock and the peripheral clock are consistent, controlled by various circadian components, and participate in the pathophysiological process of astrocytes. Existing evidence shows that circadian rhythm controls the regulation of inflammatory responses by astrocytes in ischemic stroke (IS), regulates the repair of the BBB, and plays an essential role in a series of pathological processes such as neurotoxicity and neuroprotection. In this review, we highlight the importance of astrocytes in IS and discuss the potential role of the circadian clock in influencing astrocyte pathophysiology. A comprehensive understanding of the ability of the circadian clock to regulate astrocytes after stroke will improve our ability to predict the targets and biological functions of the circadian clock and gain insight into the basis of its intervention mechanism.

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Intravenous thrombolysis before mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion; should we cross that bridge? A systematic review and meta-analysis of 36,123 patients

Cited by 16 publications

References 66 publications

When the practice does not meet the theory: results from an Italian survey on the clinical and pathway management of inpatients with decompressive craniectomy or cranioplasty admitted to rehabilitation

When the practice does not meet the theory: results from an Italian survey on the clinical and pathway management of inpatients with decompressive craniectomy or cranioplasty admitted to rehabilitation

Intravenous Thrombolysis before Thrombectomy Improves Functional Outcome after Stroke Independent of Reperfusion Grade

The role of circadian clock in astrocytes: From cellular functions to ischemic stroke therapeutic targets

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