Adjunctive Intra-arterial Thrombolysis in Endovascular Thrombectomy

Abstract

ObjectiveTo evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) as an adjunct to endovascular thrombectomy (EVT) in ischemic stroke, we performed a systematic review and meta-analysis of the literature.MethodsSearches were performed using MEDLINE, Embase, and Cochrane databases for studies that compared EVT with EVT with adjunctive IAT (EVT + IAT). Safety outcomes included symptomatic intracerebral hemorrhage and mortality at 3 months. Efficacy outcomes included successful reperfusion (Thrombolysis in Cerebral Infarction score of 2b–3) and functional independence, defined as a modified Rankin Scale score of 0–2 at 3 months.ResultsFive studies were identified that compared combined EVT + IAT (IA alteplase or urokinase) with EVT only and were included in the random-effects meta-analysis. There were 1693 EVT patients, including 269 patients treated with combined EVT + IAT and 1,424 patients receiving EVT only. Pooled analysis did not demonstrate any differences between EVT + IAT and EVT only in rates of symptomatic intracerebral hemorrhage (odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.20–1.85; p = 0.78), mortality (OR: 0.77, 95% CI: 0.54–1.10; p = 0.15), or successful reperfusion (OR: 1.05, 95% CI: 0.52–2.15; p = 0.89). There was a higher rate of functional independence in patients treated with EVT + IAT, although this was not statistically significant (OR: 1.34, 95% CI: 1.00–1.80; p = 0.053).ConclusionAdjunctive IAT appears to be safe. In specific situations, neurointerventionists may be justified in administering small doses of intra-arterial alteplase or urokinase as rescue therapy during EVT.

Prediction of delayed reperfusion in patients with incomplete reperfusion following thrombectomy

“…3–5 Potential adjunctive reperfusion efforts include secondary distal MT, administration of intra-arterial lytic, or additional antithrombotics. 12–17…”

“…12,13,18 Other adjunctive reperfusion efforts would include the administration of intra-arterial lytics or antithrombotics. [14][15][16][17] Although intra-arterial lytics are thought to be less invasive than mechanical therapies, they may increase the risk of bleeding. 19,20 In summary, several propositions have been made for different adjunctive reperfusion strategies, but none of them are devoid of risk.…”

“…19,20 In summary, several propositions have been made for different adjunctive reperfusion strategies, but none of them are devoid of risk. [12][13][14][15][16][17] Taking these risks may be unwarranted in patients who are likely to develop DR, which is associated with lack of infract growth and a comparable outcome to patients with primary eTICI3 reperfusion. 8 Therefore, a better prediction of what patients show a naturally benign disease progression may be of value.…”

Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy

“…Accurate prediction of perfusion outcome may help in the selection of patients for e.g. intra-arterial thrombolysis [35,36] administration of antithrombotics [37,38] or secondary distal MT [39,40]. While potentially beneficial, all of these treatments also harbor a risk of harm, warranting a careful patient selection.…”

Insight Into the Mechanism of Exercise Preconditioning in Ischemic Stroke

“…Ischemic stroke accounts for up to 80% of all strokes and is one of the most fatal global diseases with rapid onset, high mortality, and high disability [ Amarenco et al, 2009 ; Hsieh et al, 2010 (accessed on 18 January 2022)]. The treatment principle behind ischemic stroke is to rapidly reconstruct blood reperfusion, restore oxygen supply to the brain, and remove harmful metabolites to reduce the cerebral infarction volume ( Bhatia et al, 2010 ; Diprose et al, 2021 ). In recent years, neuroprotective agents have been studied based on anti-oxidation, anti-apoptosis, inhibition of excitatory amino acid release, anti-inflammation, vascular neuroprotection, and nanoparticles ( Subedi and Gaire, 2021a ; Chen et al, 2021 ; Zheng et al, 2021 ; Kaur and Sharma, 2022 ).…”