Efficacy and safety of bridging thrombolysis initiated before transfer in a drip-and-ship stroke service

Abstract

ObjectiveData regarding the efficacy and safety of bridging thrombolysis (BT) initiated before transfer for evaluation of endovascular therapy is heterogeneous. We, therefore, analyse efficacy and safety of BT in patients treated within a drip-and-ship stroke service.MethodsConsecutive adult patients suffering from acute ischaemic stroke and large-vessel occlusions (LVO) transferred to our comprehensive stroke centre for evaluation of endovascular therapy in 2017–2020 were identified from a local prospective stroke database and categorised according to BT and no-BT. BT was defined as intravenous thrombolysis initiated before transfer. LVO was assessed before and after transfer. Functional outcome before stroke and at 3 months using the modified Rankin scale (mRS) was determined. Excellent outcome was defined as mRS 0–1 or return to prestroke mRS. For safety analysis, intracranial haemorrhages and mortality at 3 months were analysed. Main analysis was limited to patients with anterior circulation stroke.ResultsOf N=714 patients, n=394 (55.2%) received BT. More patients in the BT group with documented LVO before transfer recanalised without endovascular therapy (n=46, 11.7%) than patients who did not receive BT before transfer (n=4, 1.3%, p<0.001). In multivariate analysis, BT was the strongest independent predictor of early recanalisation (adjusted OR 10.9, 95% CI 3.8 to 31.1, p<0.001). BT tended to be an independent predictor of an excellent outcome at 3 months (adjusted OR 1.38, 95% CI 0.97 to 1.96, p=0.077). There were no differences in safety between the BT and no-BT groups.ConclusionsBT initiated before transfer was a strong independent predictor of early recanalisation.

European Stroke Organisation – European Society for Minimally Invasive Neurological Therapy expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion

“…49 These findings were reproduced by a single-centre German study that reported higher rates of excellent functional outcome (mRS scores 0-1 or return to prestroke mRS-score) in 'drip-and-ship patients' receiving bridging therapy (23% vs. 14%). 46 There were no differences in the two groups with regard to safety outcomes including mortality and sICH. Finally, an analysis of the French Endovascular Treatment in Ischemic Stroke (ETIS) registry 50 reported that among 1,507 patients with anterior circulation LVO stroke treated with MT at three comprehensive stroke centres, 975 (64.7%) received prior IVT.…”

“…We conducted a meta-analysis of observational studies comparing direct MT with bridging therapy in drip-and-ship patients (Table 4). 46,49,50 The pooled ORs for the association between direct MT and good and excellent functional outcomes were 0.63 (95% CI: 0.48-0.83, p=0.001, Figure 10) and 0.42 (95% CI: 0.16-1.09, p=0.07, I 2 =45%, p=0.07, Figure 11), respectively. The probability of reduced disability was lower in the direct MT group compared with the bridging therapy group (adjusted cOR 0.22 [95% CI 0.07-0.69], p=0.01), but this result was based on a single study.…”

“…44,45 Finally, the proportion of LVO 'drip-and-ship' patients who may successfully recanalize during transfer to comprehensive centres without receiving MT is approximately nine-fold higher in bridging therapy compared to direct MT (11.7% vs. 1.3%) according to the findings of a single-centre German study. 46 In the French multicentre PREDICT-RECANAL study of 686 IVT-treated patients referred for MT, early recanalization (mTICI ≥2b) after IVT was independently associated with the drip-and-ship paradigm (adjusted OR 3.3, 95% CI: 1.8-6.0), with respective recanalization rates of 24.2% and 11.1% in drip-and-ship and mothership patients after centralized reading of arterial images. 47 Similarly, a Swiss study reported higher complete recanalization rates before MT in IVT-treated patients according to the drip-and-ship model compared to the mothership model (13.6% vs. 6.2).…”

European Stroke Organisation (ESO)–European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion

“…for direct MT). 46 There were no differences in the two groups with regard to safety outcomes including mortality and sICH. Finally, an analysis of the French Endovascular Treatment in Ischemic Stroke (ETIS) registry 50 reported that among 1507 patients with anterior circulation LVO stroke treated with MT at three comprehensive stroke centers, 975 (64.7%) received prior IVT.…”

“…44 45 Finally, the proportion of LVO 'drip and ship' patients who may successfully recanalize during transfer to comprehensive centers without receiving MT is approximately nine-fold higher in bridging therapy compared with direct MT (11.7% vs 1.3%), according to the findings of a single-center German study. 46 In the French multicenter PREDICT-RECANAL study of 686 IVT-treated patients referred for MT, early recanalization (mTICI ≥2 b) after IVT was independently associated with the drip-and-ship paradigm (adjusted OR 3.3, 95% CI 1.8 to 6.0), with respective recanalization rates of 24.2% and 11.1% in drip-and-ship and mothership patients after centralized reading of arterial images. 47 Similarly, a Swiss study reported higher complete recanalization rates before MT in IVT-treated patients according to the drip-and-ship model compared with the mothership model (13.6% vs 6.2).…”