Time to Stop Looking at Alteplase for Stroke Through a Prism

Gilbert, Brian W.; Huffman, Joel B.

doi:10.1177/0897190019840116

Cited by 3 publications

(3 citation statements)

References 9 publications

(8 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…[18][19][20] Since the approval of IVT for the treatment of ischemic stroke by the FDA in 1996, there has been a debate about the benefit and potential harm of IVT administration and about the optimal treatment candidate selection. [21][22][23][24][25][26][27] A previous comprehensive meta-analysis of individual patient data from randomized trials observed that IVT improves the overall odds of good outcomes when delivered within 4.5 hours, irrespective of age and NIHSS. 28 Regarding the degree of early ischemic changes, previous landmark trials evaluating the effect of IVT excluded patients with early ischemic changes in >1/3 of the MCA territory, while other studies concluded not to have enough statistical power to ascertain whether IVT adds risk or benefit (i.e., in patients with ASPECTS 0-7).…”

Section: Discussionmentioning

confidence: 99%

“…Since the approval of IVT for the treatment of ischemic stroke by the FDA in 1996, there has been a debate about the benefit and potential harm of IVT administration and about the optimal treatment candidate selection 21–27 . A previous comprehensive meta‐analysis of individual patient data from randomized trials observed that IVT improves the overall odds of good outcomes when delivered within 4.5 hours, irrespective of age and NIHSS 28 .…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS

Broocks

Heit

Kuraitis

et al. 2022

Annals of Neurology

View full text Add to dashboard Cite

Purpose Baseline variables could be used to guide the administration of additional intravenous alteplase (IVT) before mechanical thrombectomy (MT). The aim of this study was to determine how baseline imaging and demographic parameters modify the effect of IVT on clinical outcomes in patients with ischemic stroke due to large vessel occlusion. Methods Multicenter retrospective cohort study of ischemic stroke patients triaged by multimodal‐CT undergoing MT treatment after direct admission to an MT‐eligible center. Inverse‐probability weighting analysis (IPW) was used to assess the treatment effect of IVT adjusted for baseline variables. Multivariable logistic regression analysis with IPW‐weighting and interaction terms for IVT was performed to predict functional independence (mRS 0‐2 at 90‐days). Results 720 patients were included, of which 366 (51%) received IVT. In IPW, the treatment effect of IVT on outcome (mRS 0‐2) distinctively varied according to the ASPECTS subgroup (ASPECTS 9‐10: +15%, ASPECTS 6‐8: +7%, ASPECTS <6: −11%). In multivariable logistic regression analysis, IVT was independently associated with functional independence (aOR: 1.57, 95% CI: 1.16‐2.14, p = 0.003) and the interaction term was significant for ASPECTS and IVT revealing that IVT was only significantly associated with better outcomes in patients with higher ASPECTS. No other significant baseline variable interaction terms were identified. Interpretation ASPECTS was the only baseline variable that showed a significant interaction with IVT for outcome prediction. Use of IVT prior to MT in patients with an ASPECTS of <6 was not associated with a treatment benefit and should be considered carefully. ANN NEUROL 2022;92:588–595

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS

Broocks

Heit

Kuraitis

et al. 2022

Annals of Neurology

View full text Add to dashboard Cite

show abstract

“…Since approval of IVT for the treatment of ischemic stroke by the FDA in 1996, there has been an ongoing debate about harm and benefit of IVT administration and about the optimal treatment selection [ 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. In 2018, the WAKE-UP trial reported a beneficial treatment effect of IVT compared to placebo despite a slightly increased rate of sICH [ 34 ].…”

Section: Discussionmentioning

confidence: 99%

Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization

Broocks

Meyer

Ruppert

et al. 2022

JCM

View full text Add to dashboard Cite

Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.

show abstract