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

Abstract

Objective Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity. Methods Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients’ baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration. Results In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006). Conclusion The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures.

Impact of ongoing intravenous thrombolysis until completion of endovascular treatment in large vessel occlusion stroke patients

“…First, ongoing IVT at ET completion was associated with good clinical outcome (mRS 0-2 or back to baseline after 90 days; OR 1.53; 95% CI 1.08-2.17; p < 0.05), and we observed increased odds of achieving a better functional outcome by ∼30% in the mRS shift analysis (OR 0.70; 95% CI 0.55-0.89; p < 0.05), which is in line with previous analyses (6,7).…”

“…Together, our findings may have substantial clinical implications. Not only are IVT and ET essentially additive, but they work particularly well together if IVT is still ongoing at the time of ET completion; this finding is consistent with recent analyses (6,7). This highlights the need for continuous optimization of in-hospital processes in order to reach FLR within 60 min after IVT.…”

“…This suggests that the results of the CHOICE trial can be applied in a real-world setting. The second study used a matched case-control analysis and found that simultaneous administration of IVT during ET (with a minimum overlap of 10 min) was beneficial for patients with large-vessel occlusion (LVO) stroke and a premodified Rankin Scale (pmRS) score of 0-3 (7).…”