Original ArticleComparison 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
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.