How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT

Ospel, Johanna M.; Kashani, Nima; Fischer, Urs; Menon, Bijoy K; Almekhlafi, Mohammed; Wilson, Adam D.; Foss, M; Saposnik, Gustavo; Goyal, Mayank; Hill, Michael D.

doi:10.3174/ajnr.a6396

Cited by 3 publications

(4 citation statements)

References 20 publications

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“…[18][19][20] Since the approval of IVT for the treatment of ischemic stroke by the FDA in 1996, there has been a debate about the benefit and potential harm of IVT administration and about the optimal treatment candidate selection. [21][22][23][24][25][26][27] A previous comprehensive meta-analysis of individual patient data from randomized trials observed that IVT improves the overall odds of good outcomes when delivered within 4.5 hours, irrespective of age and NIHSS. 28 Regarding the degree of early ischemic changes, previous landmark trials evaluating the effect of IVT excluded patients with early ischemic changes in >1/3 of the MCA territory, while other studies concluded not to have enough statistical power to ascertain whether IVT adds risk or benefit (i.e., in patients with ASPECTS 0-7).…”

Section: Discussionmentioning

confidence: 99%

“…Since the approval of IVT for the treatment of ischemic stroke by the FDA in 1996, there has been a debate about the benefit and potential harm of IVT administration and about the optimal treatment candidate selection 21–27 . A previous comprehensive meta‐analysis of individual patient data from randomized trials observed that IVT improves the overall odds of good outcomes when delivered within 4.5 hours, irrespective of age and NIHSS 28 .…”

Section: Discussionmentioning

confidence: 99%

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Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS

Broocks

Heit

Kuraitis

et al. 2022

Annals of Neurology

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Purpose Baseline variables could be used to guide the administration of additional intravenous alteplase (IVT) before mechanical thrombectomy (MT). The aim of this study was to determine how baseline imaging and demographic parameters modify the effect of IVT on clinical outcomes in patients with ischemic stroke due to large vessel occlusion. Methods Multicenter retrospective cohort study of ischemic stroke patients triaged by multimodal‐CT undergoing MT treatment after direct admission to an MT‐eligible center. Inverse‐probability weighting analysis (IPW) was used to assess the treatment effect of IVT adjusted for baseline variables. Multivariable logistic regression analysis with IPW‐weighting and interaction terms for IVT was performed to predict functional independence (mRS 0‐2 at 90‐days). Results 720 patients were included, of which 366 (51%) received IVT. In IPW, the treatment effect of IVT on outcome (mRS 0‐2) distinctively varied according to the ASPECTS subgroup (ASPECTS 9‐10: +15%, ASPECTS 6‐8: +7%, ASPECTS <6: −11%). In multivariable logistic regression analysis, IVT was independently associated with functional independence (aOR: 1.57, 95% CI: 1.16‐2.14, p = 0.003) and the interaction term was significant for ASPECTS and IVT revealing that IVT was only significantly associated with better outcomes in patients with higher ASPECTS. No other significant baseline variable interaction terms were identified. Interpretation ASPECTS was the only baseline variable that showed a significant interaction with IVT for outcome prediction. Use of IVT prior to MT in patients with an ASPECTS of <6 was not associated with a treatment benefit and should be considered carefully. ANN NEUROL 2022;92:588–595

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS

Broocks

Heit

Kuraitis

et al. 2022

Annals of Neurology

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“…Since approval of IVT for the treatment of ischemic stroke by the FDA in 1996, there has been an ongoing debate about harm and benefit of IVT administration and about the optimal treatment selection [ 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. In 2018, the WAKE-UP trial reported a beneficial treatment effect of IVT compared to placebo despite a slightly increased rate of sICH [ 34 ].…”

Section: Discussionmentioning

confidence: 99%

Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization

Broocks

Meyer

Ruppert

et al. 2022

JCM

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Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.

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“…International studies illustrated the most common factors associated with therapeutic decisions even when there are no specific guidelines. Overall, most investigators are applying current guidelines to optimize delivery of reperfusion therapies [5][6][7]. However, the existing main solutions (e.g., telestroke and regionalization of stroke care) have practical limitations to effectively delivering reperfusion therapies [3].…”

Section: Introductionmentioning

confidence: 99%

Comparing performance measures and clinical outcomes between mobile stroke units and usual care in underserved areas

et al. 2022

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Background The efficacy of mobile stroke units (MSUs) in improving acute ischemic stroke (AIS) care in developing countries is unknown. We compared performance measures and stroke outcomes in AIS patients between MSU and usual care: emergency medical services (EMS) and walk-in. Methods We enrolled patients > 18 years of age with an AIS within 4.5 h after onset. Demographic data, types, and time of reperfusion therapies and clinical outcomes were recorded. A favorable outcome was defined as a modified Rankin Scale (mRS) 0–2 at 3 months. Results A total of 978 AIS patients (MSU = 243, EMS = 214, walk-in = 521) were enrolled between June 1, 2018, and April 30, 2021. The mean age (± SD) was 66 (± 14) years, and 510 (52.1%) were male. AIS time metrics were the shortest in the MSU with a mean (± SD) door to needle (DN) time of 20 (± 7), 29 (± 13), and 35 (± 16) min (p < 0.001) and door to puncture (DP) time of 73 ± 19, 86 ± 33, and 101 ± 42 min (p < 0.001) in MSU, EMS, and walk-in, respectively. Participants in the MSU (56.8%) received higher rate of reperfusion therapie(s) when compared to the EMS (51.4%) and walk-in (31.5%) (p < 0.001). After adjustment for any potential confounders and using the EMS as a reference, the MSU has the highest likelihood of achieving a favorable outcome (adjusted OR 2.15; 95% CI 1.39–3.32). Conclusions In underserved populations, MSUs significantly reduced DN time, increased the likelihood of receiving reperfusion treatment, and achieved independency at 3 months when compared to usual care.

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How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT

Cited by 3 publications

References 20 publications

Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS

Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS

Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization

Comparing performance measures and clinical outcomes between mobile stroke units and usual care in underserved areas

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