Is bridging therapy still required in stroke due to carotid artery terminus occlusions?

Bourcier, Romain; Pawlik, Alexandre; Eugène, François; Delasalle-Guyomarch, Béatrice; Guillon, Benoı̂t; Kerleroux, Basile; Saleme, Suzana; Marnat, Gaultier; Boucebci, S.; Mirza, Mahmood; Ferré, Jean-Christophe; Papagiannaki, Chrysanthi; Desal, Hubert

doi:10.1136/neurintsurg-2017-013398

Cited by 33 publications

(33 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…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%

“…Several recent studies looked at individual or pooled data from recent observational or randomized studies yielding conflicting results [20][21][22][23][24][25][26]. Thus, while most did not find differences in outcome between dEVT and bridging [20,22,24], some found advantages for dEVT [21,25], while still others were able to detect benefit for bridging over dEVT [26]. In a recent topical review article summarizing the data up to date, there were no conclusive recommendations that could be drawn regarding which strategy was better but it was noted that dEVT may be noninferior to bridging [27].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

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

et al. 2018

View full text Add to dashboard Cite

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.

show abstract

Section: Discussionsupporting

confidence: 78%

Section: Introductionmentioning

confidence: 99%

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

et al. 2018

View full text Add to dashboard Cite

show abstract

“…[36][37][38] For this reason, we performed additional analyses adjusting for potential confounders, as provided in original publications. Even studies evaluating only patients treated with dMT without contraindications to IVT should not be considered free from selection bias, given that treatment decisions were not based on predefined criteria, but were rather arbitrary.…”

Section: Discussionmentioning

confidence: 99%

“…Even studies evaluating only patients treated with dMT without contraindications to IVT should not be considered free from selection bias, given that treatment decisions were not based on predefined criteria, but were rather arbitrary. [36][37][38] For this reason, we performed additional analyses adjusting for potential confounders, as provided in original publications. Although IVT pretreatment was not associated with time delays in endovascular reperfusion therapies (see Supplementary Tables 12 and 13), we were unable to explore for potential disparities in the outcomes of interest according to concurrent medications, thrombus location, and other neuroimaging parameters.…”

Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Katsanos

Malhotra

Goyal

et al. 2019

Annals of Neurology

View full text Add to dashboard Cite

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.

show abstract

“…However, the results of these studies are difficult to apply to CAO, since most of them included few cases of patients with carotid involvement. Similarly, recent studies have compared the effect of bridging therapy with IVT (BT) with primary MT (PMT) in the treatment of LVO [12][13][14][15][16][17][18][19][20], but most of these studies excluded patients with CAOs, especially those affecting the extracranial carotid segment and tandem occlusions.…”

Section: Introductionmentioning

confidence: 99%

Mechanical Thrombectomy in Acute Stroke Due to Carotid Occlusion: A Series of 153 Consecutive Patients

et al. 2018

View full text Add to dashboard Cite

Background: Strokes due to carotid artery occlusion (CAO) are associated with bad clinical prognosis and poor response to intravenous thrombolysis. Several studies in the past have shown the benefits of mechanical thrombectomy (MT) and compared bridging therapy (BT) and primary MT (PMT) in large vessel occlusions, but only a few studies have focused on the specific population of CAO and their response to endovascular treatment. Methods: Retrospective review of patients treated at our center between January 2010 and June 2017 that (1) presented with acute ischemic stroke caused by CAO in the first 4.5 h since symptom onset, and (2) were treated with MT (BT or PMT). Baseline characteristics of the population, comparison between BT and PMT, intrahospital mortality, symptomatic intracranial hemorrhage, and functional outcome were investigated. Results: A total of 153 patients were included. Baseline characteristics: 51.6% were male, and the median age was 71 years. The most frequent risk factor was hypertension (71.9%). The main stroke etiology was atherothrombotic (40.5%). The mean admission National Institute of Health Severity Score (NIHSS) was 19, mean discharge NIHSS was 7. Isolated occlusion of the Extracranial or Intracranial Internal Carotid Artery was the most frequent occlusion location (52.3%). TICI 2b-3 was achieved in 87.6%, intrahospital mortality was 26.8%, symptomatic hemorrhage was 8.5%, and 3 months-modified Rankin Score (mRS) 0–2 was 26.8%. Definitive carotid stenting was needed in 33.3% of the cases. BT versus PMT: Patients treated with PMT presented a higher incidence of atrial fibrillation, anticoagulation, and cardioembolic stroke compared to those treated with BT. No differences in TICI 2b-3, 3 months-mRS or symptomatic hemorrhage were found between both groups. Intrahospital mortality: Poor perfusion-CT mismatch (p = 0.005), isolated Internal carotid artery location (p = 0.024), and symptomatic hemorrhage (p < 0.001) were independent predictors. Symptomatic intracranial hemorrhage: Patients with post-treatment symptomatic hemorrhage had higher intrahospital mortality (p < 0.001) and worse 3 months-mRS (p = 0.033). Functional outcome: Admission NIHSS (p = 0.012) independently predicted 3 months-mRS. Conclusions: In our population, patients with CAO clinically present with severe strokes. Isolated occlusions of the extra- or intracranial segments of the carotid are more frequent than tandem occlusions. Successful recanalization after thrombectomy is achieved in most of the patients, but association with favorable functional outcome is poor. Clinical evolution is similar in patients treated with PMT and BT. Intracranial symptomatic hemorrhage after treatment is associated with higher intrahospital mortality and worse 3 months-mRS. Poor perfusion-CT mismatch, symptomatic hemorrhage, and isolated CAO are independent predictors of intrahospital mortality. Admission NIHSS is an independent predictor of 3 months-mRS.

show abstract

Is bridging therapy still required in stroke due to carotid artery terminus occlusions?

Abstract: There was no significant difference in clinical outcomes between patients receiving bridging therapy versus direct thrombectomy. Bridging therapy delayed time to groin puncture and increased ICH rate.

Cited by 33 publications

References 24 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

Mechanical Thrombectomy in Acute Stroke Due to Carotid Occlusion: A Series of 153 Consecutive Patients

Contact Info

Product

Resources

About