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

Abstract

Current guidelines advocate intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for all patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We evaluated outcomes with and without IVT pretreatment. Our institutional protocols allow AIS patients presenting early (<4 h from onset or last seen normal) who have an Alberta Stroke Program Early CT Score (ASPECTS) ≥6 to undergo EVT without IVT pretreatment if the endovascular team is in the hospital (direct EVT). Rates of recanalization and hemorrhagic transformation (HT) and neurological outcomes were retrospectively compared in consecutive patients undergoing IVT+EVT vs. direct EVT with subanalyses in those ≥80 years and ≥85 years. In the overall cohort (IVT+EVT = 147, direct EVT = 162), and in subsets of patients ≥80 years (IVT+EVT = 51, direct EVT = 50) and ≥85 years (IVT+EVT = 19, direct EVT = 32), the IVT+EVT cohort and the direct EVT group had similar baseline characteristics, underwent EVT after a comparable interval from symptom onset, and reached similar rates of target vessel recanalization. No differences were observed in the HT frequency, or in disability at discharge or after 90 days. Patients receiving direct EVT underwent more stenting of the carotid artery due to stenosis during the EVT procedure (22% vs. 6%, p = 0.001). Direct EVT and IVT+EVT had comparable neurological outcomes in the overall cohort and in the subgroups of patients ≥80 and ≥85 years, suggesting that direct EVT should be considered in patients with an elevated risk for HT.

The pivotal role of timing of intravenous thrombolysis bridging treatment prior to endovascular thrombectomy

“…These studies reported no association with the occlusion site, age, or the presence of atrial fibrillation. [32][33][34] A post hoc analysis of the MR-CLEAN-NO-IV trial has demonstrated an association with the first-line thrombectomy technique used. 35 Other parameters may include pre-treatment with antiplatelets or statins.…”

Current advances in endovascular treatment

“…As the impact of bridging treatment may differ across subpopulations, better patients’ selection is warranted, distinguishing those who may benefit or conversely be harmed by the IVT+EVT approach. Recent studies reported no association between IVT+EVT treatment effect and the occlusion site, age or the presence of atrial fibrillation [14 ▪ ,15,16]. A posthoc analysis of the MR-CLEAN-NO-IV trial has demonstrated association between treatment effect and the first-line thrombectomy technique used [17].…”

Age Is Only a Number Also in Hyperacute Stroke Care—But Not an Irrelevant One

“…However, this therapy is only available in comprehensive stroke centers and requires advanced neurovascular expertise in its provision and patient selection. It is also uncertain whether EVT is better used with or without preceding thrombolysis, and the efficacy of both of these therapies is highly time-dependent [ 2 , 3 , 4 , 5 , 6 ]. Therefore, these advancements have created new challenges in the design of efficient provision strategies regarding acute stroke care services.…”

“…Ultrasound techniques for the pre-hospital identification of LVO in octogenarians should also quickly be evaluated because, in a drip-n-ship setting, these patients might particularly benefit from being transferred directly to an EVT-capable center [ 6 , 27 ]. The strategy of skipping tPA in EVT-eligible LVO patients with a high risk of hemorrhage may also be considered [ 3 ].…”