Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke

Coutinho, Jonathan M.; Liebeskind, David S; Slater, Lee-Anne; Nogueira, Raul G; Clark, Wayne M.; Dávalos, Antoni; Bonafé, Alain; Jahan, Reza; Fischer, Urs; Gralla, Jan; Saver, Jeffrey L.; Pereira, Vítor Mendes

doi:10.1001/jamaneurol.2016.5374

Cited by 203 publications

(143 citation statements)

References 23 publications

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“…In the present study, age and admission NIHSS were identified as prognostic factors on multivariate analyses but treatment allocation did not influence outcome. This is in agreement with a smaller single-center pilot study that examined the effects of bridging versus dEVT on outcome and found no such impact [18] as well as with several other retrospective studies [22,23,[33][34][35] and prospective registry data [20,21,24] that did not find differences in outcome between patients treated with bridging and those treated with dEVT. In contrast, other retrospective studies found lower mortality rates [23], lower symptomatic hemorrhage rates and higher reperfusion rates in patients treated with dEVT [36] while two meta-analyses on the subject found evidence for lowering mortality and severe disability rates with bridging [26,37].…”

Section: Discussionsupporting

confidence: 90%

“…Several recent studies looked at individual or pooled data from recent observational or randomized studies yielding conflicting results [20][21][22][23][24][25][26]. Thus, while most did not find differences in outcome between dEVT and bridging [20,22,24], some found advantages for dEVT [21,25], while still others were able to detect benefit for bridging over dEVT [26]. In a recent topical review article summarizing the data up to date, there were no conclusive recommendations that could be drawn regarding which strategy was better but it was noted that dEVT may be noninferior to bridging [27].…”

Section: Introductionmentioning

confidence: 99%

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Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

et al. 2018

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Background and Aims: Patients with emergent large-vessel occlusion (ELVO) that present earlier than 4 h from onset are usually treated with bridging systemic thrombolysis followed by endovascular thrombectomy (EVT). Whether direct EVT (dEVT) could improve the chances of favorable outcome remains unknown. Methods: Consecutively, prospectively enrolled patients with ELVO presenting within 4 h of onset were entered into a National Acute Stroke Registry of patients undergoing revascularization. Patients treated with bridging were compared to those treated with dEVT. Excellent outcome was defined as having a modified Rankin Scale score ≤1 at 90 days following stroke. Results: Out of 392 patients that underwent thrombectomy, 270 (68%) presented within 4 h and were included. Of those, 159 (59%) underwent bridging and 111 (41%) underwent dEVT. Atrial fibrillation and congestive heart failure were more common in the dEVT group (43 vs. 30%, p = 0.04 and 20 vs. 8%, p = 0.009, respectively), but other risk factors, demographics, stroke severity and subtypes as well as baseline vessel patency state and time metrics did not differ. Excellent target vessel recanalization defined as TICI 3 (thrombolysis in cerebral infarction score) was more common in the dEVT group (75 vs. 61%, p = 0.03), but in-hospital mortality, discharge destinations, short- and long-term excellent outcome rates did not differ. On multivariate regression analysis, treatment modality did not significantly modify the chances of excellent outcome at discharge (OR 0.7; 95% CI 0.3–1.5) or at 3 months (OR 0.78 95% CI 0.4–1.4). Conclusions: The chances of attaining excellent functional outcomes are similar in ELVO patients undergoing dEVT or bridging.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

et al. 2018

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“…In our analysis, we chose to include only patients treated with IV thrombolysis prior to thrombectomy, given that the potential benefit of admission to the closest primary stroke center is to offer IV thrombolysis sooner. Some authors reported similar thrombectomy outcomes with and without thrombolysis [17,18]. However, a recent meta-analysis demonstrated that patients treated by bridging therapy have better functional outcomes and lower mortality, without increasing symptomatic ICH risk compared with patients treated with mechanical thrombectomy alone [19].…”

Section: Discussionmentioning

confidence: 99%

Direct Admission versus Secondary Transfer for Acute Stroke Patients Treated with Intravenous Thrombolysis and Thrombectomy: Insights from the Endovascular Treatment in Ischemic Stroke Registry

et al. 2019

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Background: To date, thrombectomy for large vessel occlusion (LVO) strokes can be performed only in comprehensive stroke centers with thrombectomy capacity. We compared the clinical outcome of patients first referred to a primary stroke center to those admitted directly to a comprehensive stroke center and treated on site in the multicentric observational Endovascular Treatment in Ischemic Stroke (ETIS) registry. Methods: From our perspective, multicenter, observational ETIS registry, we analyzed anterior circulation stroke patients, treated within 8 h, who underwent thrombectomy after thrombolysis and were admitted to a comprehensive stroke center either with drip and ship or mothership. Clinical and safety outcomes were compared between 2 groups. Results: A total of 971 patients were analyzed: 298 were treated with the mothership approach and 673 with drip and ship. Significantly more functional independence (90-day modified Rankin Scale [mRS] 0–2) was achieved in mothership (60.1%) than in drip and ship patients (52.6%; adjusted relative risk [RR] 0.87, 95% CI 0.77–0.98, p = 0.018). Excellent outcome (90-day mRS 0–1) was achieved in 45.3% of the mothership group, compared to 37.9% of the drip and ship group (RR 0.84, 95% CI 0.71–0.98; p = 0.026). According to the distance between the primary stroke center and the comprehensive stroke center, greater functional independence was achieved in mothership than in drip and ship >12.5 miles patients (adjusted RR 0.82; 95% CI 0.71–0.94). Results in the drip-ship group stratified according to time between cerebral imaging and groin puncture (categorized according to the median cut-off: 140 min) were similar. Symptomatic intracerebral hemorrhage rate and mortality within 90 days was similar in both groups (7.5 vs. 5.9%, p = 0.40; 17.4 vs. 16.1%, p = 0.63). Conclusions: Our study suggests that LVO stroke patients directly admitted to a comprehensive stroke center present a higher chance of functional independence, especially when the distance between the primary stroke center and comprehensive stroke center is >12.5 miles or when the time between cerebral imaging and groin puncture is ≥140 min.

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“…A large majority supported bypassing ACH when LVO was suspected despite the lack of randomized controlled trial proving that such a model would improve outcomes for LVO cases and not significantly penalize non-LVO patients delayed in receiving IV tPA by mistriage. This indicates that the responders believed that endovascular therapy is the optimal treatment modality for LVO patients with IV alteplase being less or even not important at all as suggested by a recent analysis [11]. The more surprising finding was that a sizable minority, 44%, supported triaging non-LVO case to the further ECH.…”

Section: Discussionmentioning

confidence: 92%

Support of New Triage Protocol among Acute Stroke Care Providers

Hussein

Anderson

2018

Intervent Neurol

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Objective: We conducted an online survey to gauge the acceptance of sending acute stroke patients with suspected large vessel occlusion (LVO) directly to an endovascular-capable hospital (ECH) even if that means bypassing a closer alteplase-capable hospital (ACH) without endovascular capability. Methods: The survey was composed of two cases of acute stroke, one with cortical symptoms suggestive of LVO and the other without. In each case, responders were asked to choose between triaging to a closer ACH or an ECH that is further away and to provide an opinion regarding the maximum extra travel time they would tolerate if they chose the ECH. The survey was sent electronically to national groups of neurologists, emergency department (ED) physicians, emergency medical service (EMS) directors, and stroke coordinators. Results: There were 320 responders from 44 states, most of them with 10 years or more of experience. Most of the responders, 72.5%, chose ECH for the LVO case, while 56% chose ACH for the non-LVO case. There were marked differences in responses by specialty: neurology strongly supported ECH for LVO and strongly supported ACH for non-LVO, most ED and EMS chose ECH for both cases, and stroke coordinators were the least supportive of bypassing ACH. Almost all groups agreed on 30 min as the acceptable extra transfer time to ECH. Conclusion: Among the survey responders, there is a broad acceptance of the idea of bypassing ACH and going straight to ECH when LVO is suspected; however, there is less agreement on triaging patients with non-LVO stroke.

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Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke

Cited by 203 publications

References 23 publications

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

Direct Admission versus Secondary Transfer for Acute Stroke Patients Treated with Intravenous Thrombolysis and Thrombectomy: Insights from the Endovascular Treatment in Ischemic Stroke Registry

Support of New Triage Protocol among Acute Stroke Care Providers

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