Intravenous Thrombolysis Is Associated with Less Disabling Stroke and Lower Mortality in Multiple-Pass Endovascular Thrombectomy

Abstract

<b><i>Background and Purpose:</i></b> The benefit of bridging intravenous thrombolysis (IVT) in acute ischaemic stroke patients eligible for endovascular thrombectomy (EVT) is unclear. This may be particularly relevant where reperfusion is achieved with multiple thrombectomy passes. We aimed to determine the benefit of bridging IVT in first and multiple-pass patients undergoing EVT ≤6 h from stroke onset to groin puncture. <b><i>Methods:</i></b> We compared 90-day modified Rankin Scale (mRS) outcomes in 187 consecutive patients with large vessel occlusions (LVOs) of the anterior cerebral circulation who underwent EVT ≤6 h from symptom onset and who achieved modified thrombolysis in cerebral ischaemia (mTICI) 2c/3 reperfusion with the first pass to those patients who required multiple passes to achieve reperfusion. The effect of bridging IVT on outcomes was examined. <b><i>Results:</i></b> Significantly more first-pass patients had favourable (mRS 0–2) 90-day outcomes (68 vs. 42%, <i>p</i> = 0.001). Multivariate analysis showed an association between first-pass reperfusion and favourable outcomes (OR 2.25; 95% CI 1.08–4.68; <i>p</i> = 0.03). IVT provided no additional benefit in first-pass patients (OR 1.17; CI 0.42–3.20; <i>p</i> = 0.76); however, in multiple-pass patients, it reduced the risk of disabling stroke (mRS ≥4) (OR 0.30; CI 0.10–0.88; <i>p</i> = 0.02) and mortality (OR 0.07; CI 0.01–0.36; <i>p</i> = 0.002) at 90 days. <b><i>Conclusion:</i></b> Bridging IVT may benefit patients with anterior circulation stroke with LVO who qualify for EVT and who require multiple passes to achieve reperfusion.

What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review

“…Subsequent meta-analyses including observational data provided inconclusive results regarding outcomes and treatment complications [ 57 , 58 , 59 , 60 , 61 , 62 ]. However, in the case of multiple passages, IVT appears to be associated with less disability and a smaller overall stroke volume [ 63 ]. The Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN)-NO IV study showed neither non-inferiority (NIM 0.8; 0.84 [0.62–1.15]) nor superiority of direct MT [ 64 ].…”

Intravenous thrombolysis before thrombectomy in acute ischemic stroke: a dual centre retrospective cohort study

“…Few studies discussed the effect of BT (bridging therapy: combined I.V. thrombolysis and mechanical thrombectomy) on FPE and clinical outcomes 3 , 4 . Neurologists and Neuro-interventionalists started to ask a question about the best pathway for AIS (Acute Ischemic Stroke), if BT or dMT (direct Mechanical Thrombectomy) is more beneficial to the outcome of patients and our health care system.…”

“…Jang et al in a meta-analysis reported that FPE was associated with favorable 90-day outcomes with less morbidity without any effect of IVT between cases with FPE or without3 . Blair et al reported in a retrospective study that patients with FPE who received IVT had no benefit as regards clinical outcome in comparison with patients with multiple passes and received IVT4 . That might be due to the thrombolysis effect of alteplase on distal infarctions due to fragmentation of the thrombus after multiple trials of thrombectomy.Li et al reported in a meta-analysis a better 90-day favorable outcome in BT than dMT which is contradictory to our study…”

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions

“…Studies advocating BT claimed that, when preceding IVT, a bridging approach could accelerate the endovascular process and achieve successful recanalization by partially cracking and fragmenting the clot, not directly accessible by thrombectomy devices. [ 5 ] Other studies recommending d-MT noted several problems in such studies, including bias in individual selection and exclusion, cost issues, and delays in treatment time from symptom onset due to the nature of BT in terms of mixing and infusion. [ 2 ] We considered all these confounding factors and pooled our results with adjusted analysis, showing that BT and d-MT have similar therapeutic outcomes.…”