Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence

Siegler, James E.; Jovin, Tudor G

doi:10.1007/s11940-020-00633-5

Cited by 5 publications

(5 citation statements)

References 92 publications

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“… 4 5 Guidelines during the COVID-19 pandemic have called for streamlined and efficient processes, 6–11 however, there remain considerable variations in management paradigms with ongoing debates, including recommendations for pre-thrombectomy airway management, intravenous thrombolysis, and antithrombotics. 12 Due to the enforcement of contact precautions, the use of personal protective equipment, and decontamination procedures for imaging and treatment facilities, it stands to reason that the COVID-19 pandemic may result in delays of acute interventions for stroke. Furthermore, delays in acute care may also be affected by local surges in COVID-19 cases as healthcare systems become overrun and resources exhausted.…”

Section: Introductionmentioning

confidence: 99%

Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration

Czap

Zha

Sebaugh

et al. 2021

J NeuroIntervent Surg

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BackgroundUnprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown.MethodsWe performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment.ResultsOf the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7–21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (βadj=-73.2, 95% CI −153.8–7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (βadj=-3.85, 95% CI −36.9–29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (βadj=-46.44, 95% CI −62.8 to – -30.0, P<0.01) and higher NIHSS (βadj=-2.15, 95% CI −4.2to – -0.1, P=0.05).ConclusionsIn this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.

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Section: Introductionmentioning

confidence: 99%

Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration

Czap

Zha

Sebaugh

et al. 2021

J NeuroIntervent Surg

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“…In addition to these randomized studies, many observational studies, systematic reviews, and meta‐analyses of nonrandomized studies have been published 4,16–20 with different and sometimes opposite conclusions on the added benefit of intravenous thrombolysis in patients treated by thrombectomy. It should be acknowledged that nonrandomized studies comparing dMT with IVT+MT are subject to biases because most of the dMT patients are not eligible for IVT because of presentation beyond the alteplase time window, anticoagulation, or other reasons that can themselves influence stroke outcome.…”

Section: Randomized Clinical Trials On Thrombectomy With or Without Intravenous Thrombolysismentioning

confidence: 99%

“…Because 6% to 26% of patients experience multifocal emboli with distal or remote occlusions, 4,38,39 intravenous thrombolysis may promote recanalization of vessels beyond the site of primary artery occlusion (Figure 1). It is also increasingly recognized that mechanical thrombectomy can fragmentate the main thrombus during retrieval, leading to secondary small or medium vessel occlusion 40 .…”

Section: Thrombolysis To Achieve Complete Reperfusionmentioning

confidence: 99%

“…With the development of mechanical thrombectomy, the role of pharmacological thrombolysis has been questioned, especially because it might increase the risk of hemorrhagic side effects 4 . Yet, even if mechanical thrombectomy achieves recanalization rates exceeding 80% in large vessel stroke, there is still room for improvement: some patients with distal occlusion or tortuous anatomy are not eligible for endovascular procedures, delay between first medical contact and actual reperfusion by thrombectomy can be as long as several hours, and distal microthrombosis is not treatable by endovascular means.…”

Section: Introductionmentioning

confidence: 99%

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Thrombolytic strategies for ischemic stroke in the thrombectomy era

Gauberti

Lizarrondo

Vivien

2021

Journal of Thrombosis and Haemostasis

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Twenty‐five years ago, intravenous thrombolysis has revolutionized the care of patients with acute ischemic stroke. Since 2015, randomized clinical trials have demonstrated that mechanical thrombectomy improves functional outcome in stroke patients over intravenous thrombolysis alone. More recently, three randomized clinical trials have suggested that mechanical thrombectomy alone is noninferior to a combined strategy with both intravenous thrombolysis and mechanical thrombectomy. In the present review, we will present the last clinical and preclinical studies on the use of thrombolysis in stroke patients in the modern thrombectomy era. At the cost of a potential increased risk of hemorrhagic transformation, thrombolysis may promote arterial recanalization before thrombectomy, improve the rate of successful recanalization after thrombectomy, and restore microcirculation patency downstream of the main thrombus. Besides, new thrombolytic strategies targeting tissue‐type plasminogen activator resistant thrombi are being developed, which could strengthen the beneficial effects of thrombolysis without carrying additional pro‐hemorrhagic effects. For instance, tenecteplase has shown improved rate of recanalization compared with tissue‐type plasminogen activator (alteplase). Beyond fibrinolysis, DNA‐ and von Willebrand factor‐targeted thrombolytic strategies have shown promising results in experimental models of ischemic stroke. New combined strategies, improved thrombolytics, and dedicated clinical trials in selected patients are eagerly awaited to further improve functional outcome in stroke.

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“…Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator has been a long-standing, evidence-based treatment approach for acute ischemic stroke [1, 2]. However, IVT is typically delivered within 4.5 h, has minimal efficacy in proximal large vessel occlusion (LVO) [3, 4], and may even increase the risk of intracranial hemorrhage [5]. Since 2015, several randomized clinical trials (RCTs) have shown robust evidence supporting the use of endovascular therapy in patients who present with an acute ischemic stroke secondary to a LVO [6–15].…”

Section: Introductionmentioning

confidence: 99%

Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis

Morsi,

Zhang,

Zhu

et al. 2023

Neuroepidemiology

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Background There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness comparing EVT with IVT versus EVT alone. Methods We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio. Results The average costs per patient were estimated to be $47,304, $49,510, $59,770 and $ 76,561 for EVT only strategy, and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90-day, 1-year, 5-year, and 20-year, respectively. The cost saving of EVT only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011, and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only to be cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons. Conclusion Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.

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Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence

Cited by 5 publications

References 92 publications

Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration

Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration

Thrombolytic strategies for ischemic stroke in the thrombectomy era

Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis

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