Mild and moderate cardioembolic stroke patients may benefit more from direct mechanical thrombectomy than bridging therapy: A subgroup analysis of a randomized clinical trial (DIRECT-MT)

Abstract

BackgroundThe benefit of intravenous alteplase before endovascular thrombectomy is unclear in patients with acute cardioembolic stroke.MethodsWe collected cardioembolic (CE) stroke patient data from the multicentre randomized clinical trial of Direct Intra-arterial Thrombectomy to Revascularize Acute Ischaemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals (DIRECT-MT). The primary outcome was the 90-day modified Rankin Scale (mRS) score. Five subgroups of cardioembolic stroke patients were analyzed. A multivariable ordinal logistic regression analysis analyzed the difference in the primary outcome between the direct mechanical thrombectomy (MT) and bridging therapy groups. An interaction term was entered into the model to test for subgroup interaction. The DIRECT-MT trial is registered with clinicaltrials.gov Identifier: NCT03469206.ResultsA total of 290 CE stroke patients from the DIRECT-MT trial were enrolled in this study: 146 patients in the direct MT group and 144 patients in the bridging therapy group. No difference between the two treatment groups in the primary outcome was found (adjusted common odds ratio, 1.218; 95% confidence interval, 0.806 to 1.841; P = 0.34). In the subgroup analysis, CE stroke patients with an NIHSS ≤ 15 in the direct MT group were associated with better outcomes (47 vs. 53, acOR, 3.14 [1.497, 6.585]) and lower mortality (47 vs. 53, aOR, 0.16 [0.026, 0.986]) than those in the bridging therapy group, while there were no significant differences between the two treatment groups in the outcome and mortality of CE stroke patients with an NIHSS >15.ConclusionMild and moderate cardioembolic stroke patients may benefit more from direct mechanical thrombectomy than bridging therapy. This need to be confirmed by further prospective studies in a larger number of patients.

Safety and efficacy of intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation

“…Among the eight included studies, six [ 27 – 29 , 31 – 33 ] were retrospective observational studies, and two [ 30 , 34 ] were prospective observational studies. The number of patients per study ranged from 94 to 2311.…”

“…The number of patients per study ranged from 94 to 2311. Four studies [ 28 , 29 , 31 , 34 ] were determined to be of good quality, and the other four studies [ 27 , 30 , 32 , 33 ] were of acceptable quality (Supplementary eTable 2 ). Characteristics of eligible studies are summarized in Table 1 .…”

“…While we did not observe any advantage of IVT plus EVT in successful reperfusion rate compared with direct EVT, we found that pre-thrombolysis enhanced functional outcomes and reduced mortality. Cao et al revealed that the rate of recanalization before intravascular therapy was notably higher in the bridging thrombolytic group than in the untreated group [ 29 ]. Consistent with our findings, Zhou et al have reported that individuals who undergo early reperfusion show improved clinical outcomes, suggesting that a certain level of reperfusion should be achieved before EVT to optimize patient prognoses [ 40 ].…”