Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?

Chandra, Ronil V.; Leslie‐Mazwi, Thabele M; Derdeyn, Colin P.; Demchuk, Andrew M.; Menon, Bijoy K; Goyal, Mayank; González, Ramón; Hirsch, Joshua A

doi:10.1136/neurintsurg-2015-012231

Cited by 81 publications

(62 citation statements)

References 54 publications

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“…8,9 Important data about the prevalence of preinterventional reperfusion was extracted from the latest large randomized trials, as shown in a recently published metaanalysis, 11 suggesting the prevalence of preinterventional reperfusion to be ≈11%. Because of the heterogeneity of reported prevalences and insufficiently detailed reperfusion quality grading, 13,20 subgroup analyses and a systematic comparison with patients not having received tPA were not performed.…”

Section: Discussionmentioning

confidence: 99%

“…These numbers increased to 13 (95% CI, [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] and 35 (95% CI, 18-464) when analysis was confined to M1 (proximal and distal) and ICA occlusions (SWIFT DIRECT trial cohort [Solitaire With the Intention for Thrombectomy Plus Intravenous t-PA Versus DIRECT Solitaire Stent-Retriever Thrombectomy in Acute Anterior Circulation Stroke], URL: http://www.clinicaltrials. gov.…”

Section: Number Needed To Treatmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9] Because tPA favors recanalization in large vessel occlusions, 10 preinterventional reperfusion obviating the need for thrombectomy is one important conceivable benefit of the bridging approach. 11 According to a recently published meta-analysis, preinterventional reperfusion occurs in about every tenth patient with an intention to bridge.…”

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confidence: 99%

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Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment

Kaesmacher

Giarrusso

Zibold³

et al. 2018

Stroke

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Background and Purpose-Preinterventional reperfusion before endovascular treatment (ET) is a benefit of bridging with intravenous tPA (tissue-type plasminogen activator). However, detailed data on reperfusion quality and rates of obviating ET in a cohort of patients with immediate access to ET is lacking. Purpose of this analysis was to evaluate prevalence and quality of preinterventional reperfusion in mothership patients. Methods-All mothership patients (n=627) from a prospective registry subjected to angiography with an intention to perform ET were reviewed. Preinterventional change of occlusion site (COS) was categorized into COS with Thrombolysis in Cerebral Infarction (TICI) 0/1, COS with TICI ≥2a, COS with TICI ≥2b, and COS with perfusion worsening. Predictors and clinical relevance were evaluated using multivariable logistic regression and results are displayed as adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI). Results-Prevalence of COS in all patients was 10.7% (95% CI, 8.3%-13.1%), subdividing into 2.7% COS with TICI 0/1, 6.2% COS with ≥TICI 2a (including 2.9% with TICI ≥2b), and 1.8% COS with perfusion worsening. Factors related to COS with ≥TICI 2a were intravenous tPA (aOR, 11.98; 95% CI, 4.5-31.6), cardiogenic thrombus origin (aOR, 2.3; 95% CI, 1.1-4.6), and thrombus length (aOR per 1 mm increase 0.926; 95% CI, 0.87-0.99). Additional ET was performed despite COS with ≥TICI 2a in 51.3%. COS with ≥TICI 2a showed a tendency for favorable outcomes (modified Rankin Scale, ≤2; aOR, 2.65; 95% CI, 0.98-7.17). Rates of COS with ≥TICI 2a were particularly low in internal carotid artery and proximal M1 occlusions (2.2%; 95% CI, 0.9%-5%), where intravenous tPA was associated with perfusion worsening (aOR, 4.33; 95% CI, 1.12-16.80). Conclusions-Prevalence of preinterventional reperfusion is non-negligible in patients with direct access to ET and is clearly favored by intravenous tPA treatment. However, it is often incomplete and often requires additional ET. Preinterventional reperfusion of internal carotid artery and proximal M1 occlusions is rare and usually of low quality, where intravenous tPA may also promote perfusion worsening.

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Section: Discussionmentioning

confidence: 99%

Section: Number Needed To Treatmentioning

confidence: 99%

mentioning

confidence: 99%

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Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment

Kaesmacher

Giarrusso

Zibold³

et al. 2018

Stroke

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“…The effect of preprocedural IV rtPA on the rates of HT is of particular interest, as there is an ongoing scientific debate on whether the bridging approach is of any benefit [46]. In particular, there are conflicting results about whether preinterventional IV rtPA actually increases the risk of HTs after ET or not [8,47,48,49,50,51].…”

Section: Discussionmentioning

confidence: 99%

Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance

Kaesmacher

Kaesmacher²,

Maegerlein³

et al. 2017

Cerebrovasc Dis

129

106

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Background: Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke, potentially associated with clinical deterioration. We attempted to identify risk factors and evaluated clinical relevance of minor and major HTs following endovascular thrombectomy (ET) in isolated middle cerebral artery (MCA) occlusions. Methods: This is a retrospective single-center analysis of 409 patients with isolated MCA occlusion treated with ET. Patients' and procedural characteristics, severity of HT according to the European Cooperative Acute Stroke Study criteria, and clinical outcomes were analyzed. Multivariate logistic regression models with standard retention criteria (p < 0.1) were used to determine risk factors and clinical relevance of HT. Results are shown as adjusted OR (aOR) and respective 95% CIs. Good neurologic short-term outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score <5 at the day of discharge. Results: Of 299 patients included, hemorrhagic infarction (HI) was detected in 87 patients, while 13 patients developed parenchymal hematoma (PH). Higher age (aOR 0.970, 95% CI 0.947-0.993, p = 0.012), eligibility for intravenous recombinant tissue plasminogen activator (IV rtPA; aOR 0.512, 95% CI 0.267-0.982, p = 0.044), and complete recanalization (TICI 3, aOR 0.408, 95% CI 0.210-0.789, p = 0.008) were associated with a lower risk of HI. Risk factors for HI included higher admission NIHSS score (aOR 1.080, 95% CI 1.010-1.153, p = 0.024) and higher admission glucose levels (aOR 1.493, 95% CI 1.170-1.904, p = 0.001). Further, female sex tended to be associated with a lower risk of HI (aOR 0.601, 95% CI 0.316-1.143, p = 0.121), while a statistical trend was observable for proximal MCA occlusion (aOR 1.856, 95% CI 0.945-3.646, p = 0.073) and a history of hypertension (aOR 2.176, 95% CI 0.932-5.080, p = 0.072) to increase risk of HI. Longer intervals from symptom onset to first digital subtraction angiography runs (aOR 1.013, 95% CI 1.003-1.022, p = 0.009), lower preinterventional Alberta Stroke Program Early CT score (aOR 0.536, 95% CI 0.307-0.936, p = 0.028) and wake-up stroke (aOR 18.540, 95% CI 1.352-254.276, p = 0.029) were associated with PH. Both, PH and HI were independently associated with lower rates of good neurologic outcome (aOR 0.086, 95% CI 0.008-0.902, p = 0.041 and aOR 0.282, 95% CI 0.131-0.606, p = 0.001). Conclusion: Risk of HI following MCA occlusion and subsequent ET is mainly determined by factors influencing infarct severity. Good recanalization results seem to be protective against subsequent HI. Our results support the notion that occurrence of PH after ET is time dependent and risk increases with more extensive early ischemic damage. Both, HI and PH do not seem to be facilitated by bridging therapy with IV rtPA or the use of oral anticoagulants, but were independently associated with more severe neurologic disability. These results support the notion that HI is not a “benign” imaging sign.

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“…In a recent commentary entitled ‘Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?’,1 we considered the advantages and disadvantages of administering intravenous tissue plasminogen activator (IV tPA) in patients also eligible for mechanical embolectomy. This generated much discussion, underscoring the topical nature of the question.…”

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confidence: 99%

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

Chandra

Leslie‐Mazwi

Hirsch

2016

J NeuroIntervent Surg

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Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?

Cited by 81 publications

References 54 publications

Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment

Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment

Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance

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

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