Julian Maingard1,2, Yasmin Shvarts3, Ronan Motyer4, Vincent Thijs5,6, Paul Brennan4, Alan O'Hare4, Seamus Looby4, John Thornton4, Joshua A Hirsch7, Christen D Barras8,9, Ronil V Chandra10,11, Mark Brooks1,2,5, Hamed Asadi1,2,5,10,11, Hong K Kok12. 1. Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Victoria, Australia. 2. School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia. 3. Monash University, Melbourne, Victoria, Australia. 4. Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland. 5. Stroke Division, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Victoria, Australia. 6. Department of Neurology, Austin Health, Melbourne, Victoria, Australia. 7. Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. 8. South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia. 9. Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia. 10. Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia. 11. Department of Imaging, Monash University, Melbourne, Victoria, Australia. 12. Interventional Radiology, Department of Radiology, Northern Hospital, Melbourne, Victoria, Australia.
Abstract
BACKGROUND: Endovascular thrombectomy (EVT) for management of large vessel occlusion (LVO) acute ischaemic stroke is now current best practice. AIM: To determine if bridging intravenous (i.v.) alteplase therapy confers any clinical benefit. METHODS: A retrospective study of patients treated with EVT for LVO was performed. Outcomes were compared between patients receiving thrombolysis and EVT with EVT alone. Primary end-points were reperfusion rate, 90-day functional outcome and mortality using the modified Rankin Scale (mRS) and symptomatic intracranial haemorrhage (sICH). RESULTS: A total of 355 patients who underwent EVT was included: 210 with thrombolysis (59%) and 145 without (41%). The reperfusion rate was higher in the group receiving i.v. tissue plasminogen activator (tPA) (unadjusted odds ratio (OR) 2.2, 95% confidence interval (CI): 1.29-3.73, P = 0.004), although this effect was attenuated when all variables were considered (adjusted OR (AOR) 1.22, 95% CI: 0.60-2.5, P = 0.580). The percentage achieving functional independence (mRS 0-2) at 90 days was higher in patients who received bridging i.v. tPA (AOR 2.17, 95% CI: 1.06-4.44, P = 0.033). There was no significant difference in major complications, including sICH (AOR 1.4, 95% CI: 0.51-3.83, P = 0.512). There was lower 90-day mortality in the bridging i.v. tPA group (AOR 0.79, 95% CI: 0.36-1.74, P = 0.551). Fewer thrombectomy passes (2 versus 3, P = 0.012) were required to achieve successful reperfusion in the i.v. tPA group. Successful reperfusion (modified thrombolysis in cerebral infarction ≥2b) was the strongest predictor for 90-day functional independence (AOR 10.4, 95% CI:3.6-29.7, P < 0.001). CONCLUSION: Our study supports the current practice of administering i.v. alteplase before endovascular therapy.
BACKGROUND: Endovascular thrombectomy (EVT) for management of large vessel occlusion (LVO) acute ischaemic stroke is now current best practice. AIM: To determine if bridging intravenous (i.v.) alteplase therapy confers any clinical benefit. METHODS: A retrospective study of patients treated with EVT for LVO was performed. Outcomes were compared between patients receiving thrombolysis and EVT with EVT alone. Primary end-points were reperfusion rate, 90-day functional outcome and mortality using the modified Rankin Scale (mRS) and symptomatic intracranial haemorrhage (sICH). RESULTS: A total of 355 patients who underwent EVT was included: 210 with thrombolysis (59%) and 145 without (41%). The reperfusion rate was higher in the group receiving i.v. tissue plasminogen activator (tPA) (unadjusted odds ratio (OR) 2.2, 95% confidence interval (CI): 1.29-3.73, P = 0.004), although this effect was attenuated when all variables were considered (adjusted OR (AOR) 1.22, 95% CI: 0.60-2.5, P = 0.580). The percentage achieving functional independence (mRS 0-2) at 90 days was higher in patients who received bridging i.v. tPA (AOR 2.17, 95% CI: 1.06-4.44, P = 0.033). There was no significant difference in major complications, including sICH (AOR 1.4, 95% CI: 0.51-3.83, P = 0.512). There was lower 90-day mortality in the bridging i.v. tPA group (AOR 0.79, 95% CI: 0.36-1.74, P = 0.551). Fewer thrombectomy passes (2 versus 3, P = 0.012) were required to achieve successful reperfusion in the i.v. tPA group. Successful reperfusion (modified thrombolysis in cerebral infarction ≥2b) was the strongest predictor for 90-day functional independence (AOR 10.4, 95% CI:3.6-29.7, P < 0.001). CONCLUSION: Our study supports the current practice of administering i.v. alteplase before endovascular therapy.
Authors: Isabel Siow; Benjamin Y Q Tan; Keng Siang Lee; Natalie Ong; Emma Toh; Anil Gopinathan; Cunli Yang; Pervinder Bhogal; Erika Lam; Oliver Spooner; Lukas Meyer; Jens Fiehler; Panagiotis Papanagiotou; Andreas Kastrup; Maria Alexandrou; Seraphine Zubel; Qingyu Wu; Anastasios Mpotsaris; Volker Maus; Tommy Anderson; Vamsi Gontu; Fabian Arnberg; Tsong Hai Lee; Bernard P L Chan; Raymond C S Seet; Hock Luen Teoh; Vijay K Sharma; Leonard L L Yeo Journal: J Stroke Date: 2022-01-31 Impact factor: 6.967