Safety and Angiographic Efficacy of Intra-Arterial Fibrinolytics as Adjunct to Mechanical Thrombectomy: Results from the INFINITY Registry

Abstract

Background and Purpose Data on safety and efficacy of intra-arterial (IA) fibrinolytics as adjunct to mechanical thrombectomy (MT) are sparse.Methods INtra-arterial FIbriNolytics In ThrombectomY (INFINITY) is a retrospective multi-center observational registry of consecutive patients with anterior circulation large-vessel occlusion ischemic stroke treated with MT and adjunctive administration of IA fibrinolytics (alteplase [tissue plasminogen activator, tPA] or urokinase [UK]) at 10 European centers. Primary outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the European Cooperative Acute Stroke Study II definition. Secondary outcomes were mortality and modified Rankin Scale (mRS) scores at 3 months.Results Of 5,612 patients screened, 311 (median age, 74 years; 44.1% female) received additional IA after or during MT (194 MT+IA tPA, 117 MT+IA UK). IA fibrinolytics were mostly administered for rescue of thrombolysis in cerebral infarction (TICI) 0-2b after MT (80.4%, 250/311). sICH occurred in 27 of 308 patients (8.8%), with an increased risk in patients with initial TICI0/1 (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1 to 5.0 per TICI grade decrease) or in those with intracranial internal carotid artery occlusions (aOR, 3.7; 95% CI, 1.2 to 12.5). In patients with attempted rescue of TICI0-2b and available angiographic follow-up, 116 of 228 patients (50.9%) showed any angiographic reperfusion improvement after IA fibrinolytics, which was associated with mRS ≤2 (aOR, 3.1; 95% CI, 1.4 to 6.9).Conclusions Administration of IA fibrinolytics as adjunct to MT is performed rarely, but can improve reperfusion, which is associated with better outcomes. Despite a selection bias, an increased risk of sICH seems possible, which underlines the importance of careful patient selection.

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

“…Intriguingly, intraarterial thrombolysis was barely considered as a rescue therapy as it is known to be an alternative option for improving reperfusion results in LVO strokes with a mechanically less invasive character. 27 Furthermore, the clinical equality of both approaches was shown in the final rates of early neurological and long-term functional outcome together with mortality at 90-days that did not differ significantly in both groups and were favorable even when considering a worst-case scenario (Table S4). Recent studies found similar results investigating different thrombectomy strategies in LVO stroke, 28,29 but also observed that contact aspiration may be more beneficial about procedural and clinical outcomes in the posterior circulation.…”

The End of Tissue-Type Plasminogen Activator’s Reign?

“…87–90 However, evidence regarding its treatment effect leading to improved outcomes is still limited. 91 Meta-analysis of RCTs evaluating IAT as stand-alone approach observed a 6.6% excess risk of sICH in patients treated with IAT as compared with controls (OR, 2.87; 8.9% versus 2.3%); however, no excess in mortality was found (20.5% versus 24.0%). 92…”

Thrombolytic strategies for ischemic stroke in the thrombectomy era

“…Although included studies were heterogeneous, some studies found improved reperfusion. Recently, results from the Intra‐arterial Fibrinolytics in Thrombectomy registry have been published 49 . Of 5612 patients screened, 311 received additional intra‐arterial fibrinolysis during or after mechanical thrombectomy, mostly because of insufficient recanalization at the end of the procedure.…”