Direct to embolectomy without IV tPA: the stage is set for a randomized controlled trial

Chandra, Ronil V.; Leslie‐Mazwi, Thabele M; Hirsch, Joshua A

doi:10.1136/neurintsurg-2016-012388

Cited by 11 publications

(5 citation statements)

References 6 publications

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“…Since the publication of landmark endovascular trials,2 use of pretreatment tPA for patients with ELVO has been questioned and is a topic of ongoing debate. Several concerns, including number of exclusion criteria for tPA therapy, its cost, delay in initiation of MT, and safety considerations, have supported the question of whether tPA should be routinely given in patients going to MT 18–21. A retrospective study demonstrated that the tPA pretreatment did not improve outcomes of patients with ELVO and the combined therapy (tPA + MT) was associated with significantly higher total and direct hospital costs than endovascular therapy alone 20.…”

Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

Goyal

Tsivgoulis

Chang

et al. 2019

J NeuroIntervent Surg

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IntroductionOne uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)).ObjectiveTo evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT.MethodsConsecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated.ResultsA total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11–20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p<0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005).ConclusionsIVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT.

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Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

Goyal

Tsivgoulis

Chang

et al. 2019

J NeuroIntervent Surg

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“…Five randomized trials reported that endovascular thrombectomy was superior to intravenous administration of alteplase for acute ischemic stroke with anterior circulation large vessel occlusions [1][2][3][4][5]. However, the effect of intravenous alteplase prior to thrombectomy on the clinical and radiological outcomes remains unclear [6][7][8][9][10]. Meta-analyses and retrospective observational studies suggest that endovascular thrombectomy alone may be inferior or equivalent to thrombectomy combined with standard alteplase treatment [6,[10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Effect of baseline infarct size on endovascular thrombectomy with or without intravenous alteplase in stroke patients: A subgroup analysis of a randomized trial (DIRECT‐MT)

Jia

Zhang

Cao

et al. 2022

Euro J of Neurology

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Background and purpose DIRECT‐MT showed that endovascular thrombectomy was noninferior to thrombectomy preceded by intravenous alteplase with regard to functional outcome in patients with acute ischemic stroke. In this post hoc analysis, we examined whether infarct size modified the effect of alteplase. Methods All patients with baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) grades were included. The primary outcome was the 90‐day modified Rankin Scale (mRS) score. Multivariate ordinal logistic regression analysis was used to calculate the adjusted common odds ratio (OR) for better functional outcome based on the mRS for thrombectomy alone versus combination therapy. An interaction term was entered to test for an interaction with baseline ASPECTS subgroups: 0–4 versus 5–7 versus 8–10. Results Of 649 patients, 323 (49.8%) were in the thrombectomy‐alone group and 326 (50.2%) in the combination‐therapy group. There was no significant treatment‐by‐trichotomized ASPECTS interaction with alteplase prior to endovascular treatment for the primary endpoint of ordinal mRS (p‐value interaction term relative to ASPECTS 8–10: ASPECTS 0–4, p = 0.386; ASPECTS 5–7, p = 0.936). Adjusted common ORs for improvement in the 90‐day mRS with thrombectomy alone compared with combination therapy were 1.99 (95% confidence interval = 0.72–5.46) for ASPECTS 0–4, 1.07 (0.62–1.86) for ASPECTS 5–7, and 1.03 (0.74–1.45) for ASPECTS 8–10. There was no significant difference in the safety outcomes between the two groups. Conclusions Baseline infarct size may not modify the effect of alteplase prior to endovascular thrombectomy with regard to favorable functional outcomes and adverse events.

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“…These results add to the debate regarding the efficacy of IV tPA in addition to EVT and ultimately a randomized controlled trial will be necessary to answer such questions [47,48]. This finding is most likely on account of patients presenting in a delayed manner deeming them ineligible for IV tPA within the 4.5-h treatment window.…”

Section: Discussionmentioning

confidence: 89%

“…Interestingly, despite a significant difference in IV tPA adminstration, rates of good functional outcome and safety parameters remained similar between early and late treatment groups. These results add to the debate regarding the efficacy of IV tPA in addition to EVT and ultimately a randomized controlled trial will be necessary to answer such questions [47,48].…”

Section: Discussionmentioning

confidence: 90%

Outcomes of endovascular treatment for acute large‐vessel ischaemic stroke more than 6 h after symptom onset

et al. 2017

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Direct to embolectomy without IV tPA: the stage is set for a randomized controlled trial

Cited by 11 publications

References 6 publications

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

Effect of baseline infarct size on endovascular thrombectomy with or without intravenous alteplase in stroke patients: A subgroup analysis of a randomized trial (DIRECT‐MT)

Outcomes of endovascular treatment for acute large‐vessel ischaemic stroke more than 6 h after symptom onset

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