Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes

Ansaar, T; Boo, SoHyun; Buseman, Chelsea; Adcock, Amelia; Tarabishy, Abdul; Miller, Maurice M.; Roberts, Thomas D.; Domico, Jennifer; Carpenter, Jeffrey

doi:10.1136/neurintsurg-2016-012830

Cited by 78 publications

(63 citation statements)

References 31 publications

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“…In the present study, age and admission NIHSS were identified as prognostic factors on multivariate analyses but treatment allocation did not influence outcome. This is in agreement with a smaller single-center pilot study that examined the effects of bridging versus dEVT on outcome and found no such impact [18] as well as with several other retrospective studies [22,23,[33][34][35] and prospective registry data [20,21,24] that did not find differences in outcome between patients treated with bridging and those treated with dEVT. In contrast, other retrospective studies found lower mortality rates [23], lower symptomatic hemorrhage rates and higher reperfusion rates in patients treated with dEVT [36] while two meta-analyses on the subject found evidence for lowering mortality and severe disability rates with bridging [26,37].…”

Section: Discussionsupporting

confidence: 78%

“…Furthermore, some studies included patients presenting up to 7 h from onset, while others only included patients presenting within 4 h from symptom onset. Moreover, while thrombectomy devices were used in most studies, others primarily used aspiration devices [19,23,33,38]. These differences probably account for the differences in outcomes observed across existing studies.…”

Section: Discussionmentioning

confidence: 78%

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Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

et al. 2018

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Background and Aims: Patients with emergent large-vessel occlusion (ELVO) that present earlier than 4 h from onset are usually treated with bridging systemic thrombolysis followed by endovascular thrombectomy (EVT). Whether direct EVT (dEVT) could improve the chances of favorable outcome remains unknown. Methods: Consecutively, prospectively enrolled patients with ELVO presenting within 4 h of onset were entered into a National Acute Stroke Registry of patients undergoing revascularization. Patients treated with bridging were compared to those treated with dEVT. Excellent outcome was defined as having a modified Rankin Scale score ≤1 at 90 days following stroke. Results: Out of 392 patients that underwent thrombectomy, 270 (68%) presented within 4 h and were included. Of those, 159 (59%) underwent bridging and 111 (41%) underwent dEVT. Atrial fibrillation and congestive heart failure were more common in the dEVT group (43 vs. 30%, p = 0.04 and 20 vs. 8%, p = 0.009, respectively), but other risk factors, demographics, stroke severity and subtypes as well as baseline vessel patency state and time metrics did not differ. Excellent target vessel recanalization defined as TICI 3 (thrombolysis in cerebral infarction score) was more common in the dEVT group (75 vs. 61%, p = 0.03), but in-hospital mortality, discharge destinations, short- and long-term excellent outcome rates did not differ. On multivariate regression analysis, treatment modality did not significantly modify the chances of excellent outcome at discharge (OR 0.7; 95% CI 0.3–1.5) or at 3 months (OR 0.78 95% CI 0.4–1.4). Conclusions: The chances of attaining excellent functional outcomes are similar in ELVO patients undergoing dEVT or bridging.

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Section: Discussionsupporting

confidence: 78%

Section: Discussionmentioning

confidence: 78%

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

et al. 2018

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“…It is also important to note that the rate of patients with prestroke disability was not reported in most of the included studies, and was used as a potential confounder in the adjusted analyses by only 2 of the studies (see Supplementary Table 14). These trials are also expected to provide reliable data on the cost-effectiveness of BT compared to dMT, as only one small study to date with 90 patients has compared the hospital costs of BT compared to dMT, 45 with other studies assessing only the cost-effectiveness of BT compared to tPA monotherapy. 44 The ongoing trials SWIFT DIRECT (Solitaire with the Intention for Thrombectomy Plus Intravenous t-PA versus Direct Solitaire Stent-Retriever Thrombectomy in Acute Anterior Circulation Stroke; NCT03192332), DIRECT-MT (Direct Intra-arterial Thrombectomy in Order to Revascularize AIS Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals; NCT03469206), MR CLEAN-NO IV (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands No IV), and DIRECT-SAFE (A Randomized Controlled Trial of Direct Endovascular Clot Retrieval versus Standard Bridging Thrombolysis with Endovascular Clot Retrieval; NCT03494920) will provide definitive answers on the potential clinical benefit of IVT pretreatment in LVO patients receiving MT.…”

Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Katsanos

Malhotra

Goyal

et al. 2019

Annals of Neurology

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Objective: The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT; IVT followed by MT) compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusion (LVO). Methods: We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post hoc analyses from randomized controlled clinical trials that provided data on the outcomes of AIS patients with LVO stratified by IVT treatment status prior to MT. Results: We identified 38 eligible observational studies (11,798 LVO patients, mean age = 68 years, 56% treated with BT). In unadjusted analyses, BT was associated with a higher likelihood of 3-month functional independence (odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.32-1.76), 3-month functional improvement (common OR [cOR] for 1-point decrease in modified Rankin Scale score = 1.52, 95% CI = 1.18-1.97), early neurological improvement (OR = 1.21, 95% CI = 1.83-1.76), successful recanalization (OR = 1.22, 95% CI = 1.02-1.46), and successful recanalization with ≤2 device passes (OR = 2.28, 95% CI = 1.43-3.64) compared to dMT. BT was also related to a lower likelihood of 3-month mortality (OR = 0.64, 95% CI = 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of 3-month functional independence (adjusted OR = 1.55, 95% CI = 1.26-1.91) and lower odds of 3-month mortality (adjusted OR = 0.80, 95% CI = 0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR = 1.24, 95% CI = 0.89-1.74) or symptomatic intracranial hemorrhage (adjusted OR = 0.87, 95% CI = 0.61-1.25).Interpretation: BT appears to be associated with improved functional independence without evidence for safety concerns, compared to dMT, for AIS patients with LVO.

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“…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%

“…11 The latter is of interest because some studies found no difference in the rates of preinterventional reperfusion in patients treated with intravenous tPA compared with those without. 12,13 Because reperfusion of large vessel occlusion after intravenous tPA was shown to be time-dependent, 10 reperfusion may not occur early enough, that is, before the start of thrombectomy, and therefore in patients with direct access to endovascular treatment (ET), the prevalence, and extent of preinterventional reperfusion associated with intravenous tPA deserves further evaluation. The aim of this analysis was to assess the prevalence and quality of ultraearly preinterventional reperfusion in a predefined cohort of patients directly admitted to a comprehensive stroke center with immediate access to ET.…”

mentioning

confidence: 99%

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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Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes

Cited by 78 publications

References 31 publications

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

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

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