Abstract:Objective
Whether bridging therapy (intravenous thrombolysis [IVT] followed by endovascular treatment) is superior to IVT alone in minor stroke with large vessel occlusion (LVO) is unknown.
Methods
Multicentric retrospective observational study including, in intention‐to‐treat, consecutive IVT‐treated minor strokes (National Institutes of Health Stroke Scale [NIHSS] ≤ 5) with LVO, with or without additional mechanical thrombectomy. Propensity‐score (inverse probability of treatment weighting) was used to reduc… Show more
“…14 Trials are underway to test the effectiveness of thrombectomy in patients with large-artery occlusion and NIHSS scores 0–5 (In Extremis/Minor Stroke Therapy Evaluation [MOSTE; NCT 03796468], Endovascular Therapy for low NIHSS Ischemic Strokes [ENDOLOW; NCT 04167527]). In addition, two recent multicentre observational studies suggest a potential beneficial effect of IVT 118 and bridging therapy 119 in acute ischaemic stroke patients with minor stroke (NIHSS-scores < 6) and large vessel occlusion.Expert consensus statement For patients with acute minor, non-disabling ischaemic stroke of < 4.5 h duration, and with large-vessel occlusion, 6 of 8 group members suggest intravenous thrombolysis with alteplase. One group member (WW) did not vote or comment on this chapter because he has been involved in the data monitoring committee of a trial related to this topic (TEMPO-2).…”
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
“…14 Trials are underway to test the effectiveness of thrombectomy in patients with large-artery occlusion and NIHSS scores 0–5 (In Extremis/Minor Stroke Therapy Evaluation [MOSTE; NCT 03796468], Endovascular Therapy for low NIHSS Ischemic Strokes [ENDOLOW; NCT 04167527]). In addition, two recent multicentre observational studies suggest a potential beneficial effect of IVT 118 and bridging therapy 119 in acute ischaemic stroke patients with minor stroke (NIHSS-scores < 6) and large vessel occlusion.Expert consensus statement For patients with acute minor, non-disabling ischaemic stroke of < 4.5 h duration, and with large-vessel occlusion, 6 of 8 group members suggest intravenous thrombolysis with alteplase. One group member (WW) did not vote or comment on this chapter because he has been involved in the data monitoring committee of a trial related to this topic (TEMPO-2).…”
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
“…The MINOR‐STROKE collaboration retrospectively collected the data from all consecutive acute stroke patients admitted to 45 French stroke centers between 2006 and 2018 who fulfilled the following criteria [11]: (i) baseline admission National Institutes of Health Stroke Scale (NIHSS) score ≤5; (ii) large vessel occlusion on pre‐treatment vascular imaging [internal carotid artery (ICA), first or second segment of middle cerebral artery (MCA), basilar artery] and (iii) treated with IVT (alteplase only), with or without additional EVT. The present study focuses on patients with iICAo intended for IVT alone, including those who eventually received rescue EVT because of post‐IVT END.…”
Background and purposeBetter understanding the incidence, predictors and mechanisms of early neurological deterioration (END) following intravenous thrombolysis (IVT) for acute stroke with mild symptoms and isolated internal carotid artery occlusion (iICAo) may inform therapeutic decisions.MethodsFrom a multicenter retrospective database, we extracted all patients with both National Institutes of Health Stroke Scale (NIHSS) score <6 and iICAo (i.e. not involving the Willis circle) on admission imaging, intended for IVT alone. END was defined as ≥4 NIHSS points increase within 24 h. END and no‐END patients were compared for (i) pre‐treatment clinical and imaging variables and (ii) occurrence of intracranial occlusion, carotid recanalization and parenchymal hemorrhage on follow‐up imaging.ResultsSeventy‐four patients were included, amongst whom 22 (30%) patients experienced END. Amongst pre‐treatment variables, suprabulbar carotid occlusion was the only admission predictor of END following stepwise variable selection (odds ratio = 4.0, 95% confidence interval: 1.3–12.2; P = 0.015). On follow‐up imaging, there was no instance of parenchymal hemorrhage, but an intracranial occlusion was now present in 76% vs. 0% of END and no‐END patients, respectively (P < 0.001), and there was a trend toward higher carotid recanalization rate in END patients (29% vs. 9%, P = 0.07). As compared to no‐END, END was strongly associated with a poor 3‐month outcome.ConclusionsEarly neurological deterioration is a frequent and highly deleterious event after IVT for minor stroke with iICAo, and is of thromboembolic origin in three out of four patients. The strong association with iICAo site—largely a function of underlying stroke etiology—may point to a different response of the thrombus to IVT. These findings suggest END may be preventable in this setting.
“…Previous studies also showed that bridging therapy was associated with significant higher rate of any hemorrhage. 14, 15 This may have contributed to the outcomes of our patients.…”
Background: It remains controversial if intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MTE) is superior to MTE alone in patients with acute ischemic stroke caused by large vessel occlusion. We aim to compare functional outcomes, mortality, reperfusion, and intracranial hemorrhage rates in bridging therapy (IVT prior thrombectomy) and MTE alone groups within 6 h from symptom onset. Materials and Methods: Consecutive hospitalized patients (September 2017 and July 2018) with acute large artery occlusion within the anterior cerebral circulation eligible for MTE with or without prior IVT were included. A modified Rankin Scale score of 0 to 2 was considered as good functional outcome at 90 days. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction scale of 2b to 3. Results: Of the 124 patients included, 56 (45.2%) received bridging therapy and 68 (54.8%) received MTE alone. Patients receiving bridging therapy were younger (median, 56 vs 63, P = .045) and had shorter onset-to-groin time (median, 270 vs 370 min, P < .001) than those receiving MTE alone. Successful reperfusion rate was significantly greater in the bridging therapy group (87.5% vs 72.1%, P = 0.03). There were no statistically significant differences between the 2 groups in functional independence (bridging 58.9% vs 75.0%, P = 0.07), mortality at 90 days (bridging 14.3% vs 7.4%, P = 0.22), parenchymal hematoma type 2 (bridging 3.6% vs 2.9%, P > .99), and any hemorrhage (bridging 42.3% vs 26.5%, P = 0.07). Conclusion: Compared to MTE alone, bridging therapy with IVT improved the reperfusion rate but not other outcomes. Further clinical trials are needed to confirm our findings.
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