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01-12-2018 | Original Communication

Effect of mechanical thrombectomy alone or in combination with intravenous thrombolysis for acute ischemic stroke

Authors: Fabrizio Sallustio, Giacomo Koch, Fana Alemseged, Daniel Konda, Sebastiano Fabiano, Enrico Pampana, Daniele Morosetti, Roberto Gandini, Marina Diomedi

Published in: Journal of Neurology | Issue 12/2018

Abstract

Objective and design

Whether combining intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) is superior to mechanical thrombectomy alone for large vessel occlusion acute ischemic stroke is still uncertain. Our aim was to compare the safety and the efficacy of these two therapeutic strategies.

Materials

Patients with acute ischemic stroke secondary to anterior circulation large vessel occlusion.

Methods

A retrospective analysis was conducted. IVT was performed with full dose recombinant tissue plasminogen activator. MT alone was performed only if intravenous thrombolysis was contraindicated. Primary outcomes were successful reperfusion, 3-month functional independence, symptomatic intracranial hemorrhage (sICH), and 3-month mortality.

Results

325 patients were analyzed: 193 treated with combined IVT and MT, 132 with MT alone. The combined treatment group showed higher systolic blood pressure (140 [80–230] vs 150 [90–220]; p = 0.036), rate of good collaterals (55.9% vs 67%; p = 0.03), use of aspiration devices (68.2% vs 79.3%; p = 0.003) and shorter onset-to-reperfusion time (300 [90–845] vs 288 [141–435]; p = 0.008). No differences were found in the efficacy and safety outcomes except for mortality which was lower in the combined treatment group (36.4% vs 25.4%; p = 0.02). However, after multivariable analysis combined treatment was not associated with lower mortality (OR 1.47; 95% CI 0.73–2.96; p = 0.3).

Conclusions

Our study suggests that mechanical thrombectomy alone is effective and safe in patients with contraindications to intravenous thrombolysis. Preceding use of IVT in eligible patients was not associated with increased harm or benefit. Randomized controlled trials are needed to clarify whether intravenous thrombolysis before mechanical thrombectomy is associated with additional benefit.

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Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20. https://doi.org/10.1056/NEJMoa1411587 CrossRefPubMed

Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018. https://doi.org/10.1056/NEJMoa1414792 CrossRefPubMed

Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030. https://doi.org/10.1056/NEJMoa1414905 CrossRefPubMed

Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295. https://doi.org/10.1056/NEJMoa1415061 CrossRefPubMed

Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306. https://doi.org/10.1056/NEJMoa1503780 CrossRefPubMed

Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731. https://doi.org/10.1016/S0140-6736(16)00163-X CrossRefPubMed

Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P et al (2018) Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378:11–21. https://doi.org/10.1056/NEJMoa1706442 CrossRefPubMed

Powers WJ, Derdeyn JP, Biller J, Coffey CS, Hoh BL, Jauch EC et al (2015) 2015 American Heart Association/American Stroke Association Focused Update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment. Stroke 46:3020–3035CrossRefPubMed

Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC et al (2016) Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 47:581–641. https://doi.org/10.1161/STR.0000000000000086 CrossRefPubMed

10.

Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C et al (2016) Mechanical thrombectomy in acute ischemic stroke: consensus-statement by Eso-Karolinska Stroke Update 2014/2015, supported by ESO/ESMINT, ESNR and EAN. Int J Stroke 11:134–147CrossRefPubMed

11.

Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 355:1670–1674CrossRefPubMed

12.

Tan JC, Dillon WP, Liu S, Adler F, Smith WS, Wintermark M (2007) Systematic comparison of perfusion-CT and CT-angiography in acute stroke patients. Ann Neurol 61:533–543. https://doi.org/10.1002/ana.21130 CrossRefPubMed

13.

Sallustio F, Motta C, Pizzuto S, Diomedi M, Giordano A, D’Agostino VC et al (2017) CT angiography-based collateral flow and time to reperfusion are strong predictors of outcome in endovascular treatment of patients with stroke. J Neurointerv Surg 9:940–943. https://doi.org/10.1136/neurintsurg-2016-012628 CrossRefPubMed

14.

Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL et al (2013) Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 44:2650–2663. https://doi.org/10.1161/STROKEAHA.113.001972 CrossRefPubMedPubMedCentral

15.

Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R et al (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 274:1017–1025CrossRefPubMed

16.

Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Clark W, Dávalos A et al (2017) Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the SWIFT and STAR studies. JAMA Neurol 74:268–274. https://doi.org/10.1001/jamaneurol.2016.5374 CrossRefPubMed

17.

Abilleira S, Ribera A, Cardona P, Rubiera M, López-Cancio E, Amaro S et al (2017) Outcomes after direct thrombectomy or combined intravenous and endovascular treatment are not different. Stroke 48:375–378. https://doi.org/10.1161/STROKEAHA.116.015857 CrossRefPubMed

18.

Mistry EA, Mistry AM, Nakawah MO, Chitale RV, James RF, Volpi JJ et al (2017) Mechanical thrombectomy outcomes with and without intravenous thrombolysis in stroke patients: a meta-analysis. Stroke 48:2450–2456. https://doi.org/10.1161/STOKEAHA.117.017320 CrossRefPubMed

19.

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S et al (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. New Engl J Med 378:708–718. https://doi.org/10.1056/NEJMoa1713973 CrossRefPubMed

20.

Sallustio F, Motta C, Koch G, Pizzuto S, Campbell BC, Diomedi M et al (2017) Endovascular stroke treatment of acute tandem occlusion: a single-center experience. J Vasc Interv Radiol 28:543–549. https://doi.org/10.1016/j.jvir.2017.01.007 CrossRefPubMed

21.

Rubiera M, Ribo M, Delgado-Mederos R, Santamarina E, Delgado P, Montaner J et al (2006) Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 37:2301–2305. https://doi.org/10.1161/01.STR.0000237070.80133.1d CrossRefPubMed

22.

Szymanski FM, Lip GY, Filipiak KJ, Platek AE, Hrynkiewicz-Szymanska A, Opolski G (2015) Stroke risk factors beyond the CHA₂DS₂-VASc score: can we improve our identification of “high stroke risk” patients with atrial fibrillation? Am J Cardiol 116:1781–1788. https://doi.org/10.1016/j.amjcard.2015.08.049 CrossRefPubMed

23.

Broeg-Morvay A, Mordasini P, Bernasconi C, Bühlmann M, Pult F, Arnold M et al (2016) Direct mechanical intervention versus combined intravenous and mechanical intervention in large artery anterior circulation stroke: a matched-pairs analysis. Stroke 47:1037–1044. https://doi.org/10.1161/STROKEAHA.115.011134 CrossRefPubMed

24.

Flint AC, Xiang B, Gupta R, Nogueira RG, Lutsep HR, Jovin TG et al (2013) THRIVE score predicts outcomes with a third-generation endovascular stroke treatment device in the TREVO-2 trial. Stroke 44:3370–3375. https://doi.org/10.1161/STROKE.AHA.113.002796 CrossRefPubMedPubMedCentral

25.

Mulder MJHL, Ergezen S, Lingsma HF, Berkhemer OA, Fransen PSS, Beumer D et al (2017) Baseline blood pressure effect on the benefit and safety of intra-arterial treatment in MR CLEAN (multicenter randomized clinical trial of endovascular treatment of acute ischemic stroke in The Netherlands). Stroke 48:1869–1876. https://doi.org/10.1161/STOKEAHA.116.01625 CrossRefPubMed

Title: Effect of mechanical thrombectomy alone or in combination with intravenous thrombolysis for acute ischemic stroke
Authors: Fabrizio Sallustio
Giacomo Koch
Fana Alemseged
Daniel Konda
Sebastiano Fabiano
Enrico Pampana
Daniele Morosetti
Roberto Gandini
Marina Diomedi
Publication date: 01-12-2018
Publisher: Springer Berlin Heidelberg
Published in: Journal of Neurology / Issue 12/2018
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-018-9073-7

At a glance: The STEP trials

Springer Medicine

Effect of mechanical thrombectomy alone or in combination with intravenous thrombolysis for acute ischemic stroke

Abstract

Objective and design

Materials

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Objective and design

Materials

Methods

Results

Conclusions

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