Outcomes After Direct Thrombectomy or Combined Intravenous and Endovascular Treatment Are Not Different

Abstract

Five recent randomized controlled trials provided clear evidence that endovascular thrombectomy (EVT) improves outcomes after acute ischemic stroke caused by large vessel occlusions (LVOs), [1][2][3][4][5] and current guidelines recommend EVT in addition to intravenous thrombolysis (IVT) within 4.5 hours among patients with anterior circulation strokes and LVO. 6,7 Patients eligible for IVT should receive it without delay even if EVT is being considered, but the particular benefit of IVT is not yet well established. Moreover, in the real world, a significant proportion of acute ischemic stroke patients receive IVT at local stroke centers where EVT is not available. Such centers apply a drip and ship protocol when an EVT candidate is identified, with the necessary subsequent transfer causing a delayed puncture. In this context, building up evidence of the specific role of IVT when added to EVT among LVO patients is necessary to reorganize stroke systems of care accordingly. We compared direct EVT (dEVT) against combined IVT+EVT in patients with anterior circulation strokes caused by LVO. MethodsWe used data included in the SONIIA registry (Sistema Online d'Informació de l'Ictus Agut), a government-mandated, populationbased, externally audited, prospective database that includes all acute ischemic stroke patients treated with reperfusion therapies in the region Background and Purpose-Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients. Methods-Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel-Haenszel test statistic. Results-We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74-1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74-1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25-1.27). of Catalonia from January 2011. Further details of this registry have been published elsewhere. 8 Briefly, the database includes relevant baseline information (prestroke medical history, medications and functional status, time of stroke onset and hospital arrival, severity, time of neuro/ vascular imaging, IVT and groin puncture time, and complications) and the neurological situation at 24 to 36 hours post-treatment, including symptomatic bleedings. Outcome variables at 3 months are good outcome (modif...

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

“…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].…”

“…Rapid target vessel recanalization is associated with higher chances for favorable outcome in patients with large-vessel occlusion [16,17] and therefore early direct EVT (dEVT) may be advantageous in these patients by shortening the time to reperfusion [18,19]. 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].…”

“…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].…”

Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance

“…In particular, there are conflicting results about whether preinterventional IV rtPA actually increases the risk of HTs after ET or not [8,47,48,49,50,51]. Somewhat counterintuitive, we have found that eligibility for IV rtPA bridging was associated with a decreased risk of subsequent HI.…”

Prevalence, risk factors and complications of oropharyngeal dysphagia in stroke patients: A cohort study

“…The first important result was that the prevalence of OD, evaluated by clinical methods, was 45.06%, which is a bit lower than previously reported results, using similar methods (51‐55%). This difference could be explained by the fact that our population had less severe stroke than other studies as the more severe cases were referred to a tertiary stroke center close to our hospital; there patients could undergo thrombectomy and invasive treatments according to The Catalan Stroke Code and Reperfusion Consortium, as explained in the exclusion criteria of our patients. Another reason why our patients were less severe is because some patients in a critical state were not able to sign the Informed Consent and could not enter the study.…”