In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

Abstract

Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Intravenous Thrombolysis Before Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta‐Analysis

“…We included 12 eligible studies (3 RCTs 19 , 20 , 21 and 9 observational studies 22 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ) for the final quantitative analysis (Figure 1 ).…”

“…Most studies only included patients with acute ischemic stroke involving the anterior circulation, except 2 studies 22 , 29 that included patients involving both anterior and posterior circulation occlusion. Among 9 observational studies, 5 studies 22 , 30 , 31 , 33 , 34 , 35 provided propensity score matching analysis results. One study 29 included patients within a 3‐hour time window.…”

“…All 5 studies performed in Western countries in this meta‐analysis were retrospectively designed. 29 , 30 , 31 , 34 , 36 We therefore could not provide clear evidence which therapy approach (dMT versus BT) might be more beneficial for Western patients with ischemic stroke. The results driven from the ongoing studies (MR CLEAN‐NO IV [Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands], ISRCTN80619088; SWIFT‐DIRECT [Solitaire With the Intention for Thrombectomy Plus Intravenous t‐PA Versus Direct Solitaire Stent‐Retriever Thrombectomy in Acute Anterior Circulation Stroke], NCT03192332; and DIRECT‐SAFE [Direct Endovascular Clot Retrieval Versus Standard Bridging Thrombolysis With Endovascular Clot Retrieval], NCT03494920) permitting direct comparison of dMT to BT will provide more data on this issue.…”

Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

“…The safety and effectiveness of administrating IV tPA prior to MT for patients with AIS is still a debatable matter. Although the current guideline recommends using the IV tPA prior to MT (BT) [ 31 ], some recent RCTs and observational studies found no significant difference in functional outcomes between patients receiving BT and dMT [ 35 , 42 , 44 , 45 , 53 , 55 , 56 , 58 , 59 ]. Furthermore, a lower rate of sICH in favor of dMT has been reported [ 42 , 53 , 55 , 59 ].…”

Direct endovascular treatment versus bridging therapy in patients with acute ischemic stroke eligible for intravenous thrombolysis: systematic review and meta-analysis

“…We deemed nine of the 73 reviewed studies to be eligible. Three RCTs (DIRECT-MT, DEVT and SKIP [20][21][22] ) and six observational studies [23][24][25][26][27][28] were included after the full texts of the studies were screened. In all nine studies, patients with AIS-LVO who were eligible to undergo both IVT and EVT were assigned to undergo direct EVT or to undergo a combined treatment with intravenous alteplase before EVT.…”