Successful Reperfusion With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large-Vessel Occlusions

Tsivgoulis, Georgios; Katsanos, Aristeidis H.; Schellinger, Peter D.; Köhrmann, Martin; Varelas, Panayiotis N.; Magoufis, Georgios; Paciaroni, Maurizio; Caso, Valeria; Alexandrov, Anne W.; Gurol, Edip M; Alexandrov, Andrei V.

doi:10.1161/strokeaha.117.019261

Cited by 150 publications

(118 citation statements)

References 13 publications

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“…8,9 Important data about the prevalence of preinterventional reperfusion was extracted from the latest large randomized trials, as shown in a recently published metaanalysis, 11 suggesting the prevalence of preinterventional reperfusion to be ≈11%. Because of the heterogeneity of reported prevalences and insufficiently detailed reperfusion quality grading, 13,20 subgroup analyses and a systematic comparison with patients not having received tPA were not performed.…”

Section: Discussionmentioning

confidence: 99%

“…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%

“…[1][2][3][4][5][6][7][8][9] Because tPA favors recanalization in large vessel occlusions, 10 preinterventional reperfusion obviating the need for thrombectomy is one important conceivable benefit of the bridging approach. 11 According to a recently published meta-analysis, preinterventional reperfusion occurs in about every tenth patient with an intention to bridge. 11 However, heterogeneity was substantial, given the lack of a precise definition of recanalization, uneven intravenous tPA to thrombectomy metrics (including drip-and-ship and directly admitted patients), and different occlusion patterns.…”

mentioning

confidence: 99%

“…11 According to a recently published meta-analysis, preinterventional reperfusion occurs in about every tenth patient with an intention to bridge. 11 However, heterogeneity was substantial, given the lack of a precise definition of recanalization, uneven intravenous tPA to thrombectomy metrics (including drip-and-ship and directly admitted patients), and different occlusion patterns.…”

mentioning

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.…”

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confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Number Needed To Treatmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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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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Endovascular thrombectomy with versus without intravascular thrombolysis for acute ischaemic stroke

Gottlieb,

Carlson,

Westrick

et al. 2024

Cochrane Database of Systematic Reviews

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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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Successful Reperfusion With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large-Vessel Occlusions

Abstract: Pretreatment with systemic thrombolysis in patients with large-vessel occlusion eligible for mechanical thrombectomy results in SR in 1 of 10 cases, negating the need for additional endovascular reperfusion. Tandem occlusions seem to be the least responsive to IVT pretreatment.

Cited by 150 publications

References 13 publications

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

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

Endovascular thrombectomy with versus without intravascular thrombolysis for acute ischaemic stroke

Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

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