Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e165-e172
World Neurosurgery

Original Article
Comparison of Outcomes After Mechanical Thrombectomy Alone or Combined with Intravenous Thrombolysis and Mechanical Thrombectomy for Patients with Acute Ischemic Stroke due to Large Vessel Occlusion

https://doi.org/10.1016/j.wneu.2018.02.126Get rights and content

Highlights

  • Previous use of IVT before MT did not facilitate successful reperfusion.

  • Previous use of IVT was not an independent predictor of favorable outcome.

  • MT alone can be safe and achieve favorable outcomes in patients with AIS.

Background

Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) provides additional benefits remains controversial. We aimed to compare clinical and radiologic outcomes between IVT+MT and MT alone groups.

Methods

We retrospectively reviewed the clinical and radiological features of patients from the prospectively collected database who sustained anterior circulation stroke due to large vessel occlusion (LVO) and were treated with MT within 8 hours of symptom onset. We compared rates of successful reperfusion, functional independence and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) as clinical endpoints between the 2 groups.

Results

The 81 patients included in this study included 38 (46.9%) in the MT alone group (mean age, 72.6 ± 14.1 years; 17 males [44.7%]) and 43 in the IVT+MT group (mean age, 68.9 ± 12.8 years; 29 males [67.4%]). There were no significant differences in patient baseline characteristics between the 2 groups except for a male predominance in the IVT+MT group. The mean interval from onset to groin puncture (221.6 ± 110.5 minutes vs. 204.7 ± 63.7 minutes; P = 0.472) and the rate of successful reperfusion rate (thrombolysis in cerebral infarction 2b/3, 60.5% vs. 58.1%; P = 0.827) did not differ significantly between the MT and IVT+MT groups. The rate of favorable functional outcome, as determined by a modified Rankin Scale score 0–2 (36.8% vs. 51.2%; P = 0.263) and mortality at 90 days (18.4% vs. 9.3%; P = 0.332), and the rate of sICH (5.3% vs. 4.6%; P = 1.000) were also not significantly different between the 2 groups.

Conclusions

This study suggests that previous IVT might not facilitate successful reperfusion and favorable functional outcomes in patients with anterior circulation stroke treated with MT. MT alone can be a safe and effective treatment modality in patients who are ineligible for IVT for various reasons.

Introduction

For several years, intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA) has been the gold standard treatment for acute ischemic stroke (AIS) within 4.5 hours of symptom onset.1 However, this therapeutic modality has shown low efficacy in patients with AIS with large vessel occlusion (LVO). Low recanalization rates of approximately 35% in middle cerebral artery occlusions and approximately 6% in carotid T occlusions have been reported.2 Five recent randomized controlled trials (RCTs) have provided clear evidence that mechanical thrombectomy (MT) with stent retrievers is superior to IVT alone in treating AIS with LVO.3, 4, 5, 6, 7 Thus, current guidelines recommend sequential MT with IVT within 4.5 hours of onset in patients with anterior circulation stroke caused by LVO.8, 9 Accordingly, tPA should be administrated in patients who are eligible for IVT without delay regardless of the consideration of MT.10 However, although only a small number of patients received MT alone, the aforementioned RCTs found no significant difference in its therapeutic effects between patients who with and those without previous IVT in a subgroup analysis.3, 4, 5, 6, 7 A recent pooled analysis of the SWIFT and STAR studies published by Coutinho et al.11 also showed that IVT before MT did not appear to provide a clinical benefit over MT alone. In contrast, some authors have suggested that previous IVT facilitates successful recanalization and improves clinical outcomes of AIS with LVO.12, 13 Thus, whether previous IVT provides additional benefits is not yet well established, and results are conflicting. Moreover, a considerable number of patients with AIS caused by LVO are ineligible for IVT due to absolute or relative contraindications for IVT, and MT alone may be a possible treatment option for these patients.

The purpose of this study was to compare the clinical and radiological outcomes between patients who underwent IVT before MT (IVT+MT group) and patients who underwent only MT (MT alone group) and to investigate whether IVT before MT provides additional benefits for reperfusion and functional outcomes compared with MT alone.

Section snippets

Study Population

Between January 2009 and June 2017, all consective patients with AIS treated with MT with or without IVT at a single tertiary institute were collected prospectively using a standardized case report form including clinical information, radiological findings, and outcomes. Patients were considered eligible who met the following inclusion criteria: (1) acute ischemic stroke due to occlusion of an anterior circulation large artery, (2) endovascular recanalization using mechanical thrombectomy

Baseline Patient Characteristics

Of the 81 patients included in this study, 38 underwent MT alone and 43 received IVT before undergoing MT for AIS caused by LVO. The most common reason for undergoing MT alone was age >80 years (n = 11), followed by >4.5 hours between known stroke onset and effective therapy (n = 9), recent major surgery (n = 7), coagulopathy (International Normalized Ratio >1.7, thrombocytopenia, or new oral anticoagulant; n = 6), recent stroke or myocardial infarction (n = 3), and other (n = 2). Baseline

Discussion

The 3 RCTs published in 2013 have contributed to the uncertainty regarding the efficacy of endovascular treatment after IVT with tPA.15, 16, 17 However, various questions have been raised regarding the design and conduct of these RCTs, including a relatively long interval before endovascular treatment, the absence of pretreatment vascular imaging to confirm LVO, and the limited use of third-generation MT devices, such as a stent retriever or suction device. Five recent RCTs were designed to

Conclusions

Our present findings suggest that previous IVT might not facilitate successful reperfusion or a favorable functional outcome in patients with anterior circulation stroke treated with MT. MT alone can be a safe and effective treatment modality in patients who are ineligible for IVT for various reasons.

Acknowledgments

We thank Yoonho Nam and Na-Young Shin for their assistance with measurements of postprocedural infarction volume on ADC mapping.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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