Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

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Abstract

Background: It is unclear whether intravenous thrombolysis (IVT) with alteplase before endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results: Using multivariable regression, we evaluated the association of IVT+EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT+EVT, and 324 (22%) with EVT alone. Patients treated with IVT+EVT had atrial fibrillation less often (16% versus 44%) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT+EVT group (median 62 versus 68 minutes). Nontransferred IVT+EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT+EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI: 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI: 0.40–0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions: In this observational study, patients treated with IVT+EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT.

Original languageEnglish
Article numbere011592
JournalJournal of the American Heart Association
Volume8
Issue number11
DOIs
Publication statusPublished - 4 Jun 2019

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Tissue Plasminogen Activator
Stroke
Therapeutics
Intracranial Hemorrhages
Reperfusion
Odds Ratio
Workflow
Mortality
Selection Bias
Groin
Punctures
Netherlands
Atrial Fibrillation
Observational Studies
Registries

Keywords

  • endovascular treatment
  • large vessel occlusion
  • stroke
  • thrombectomy
  • thrombolysis

Cite this

@article{aaf2a55ec3174f088a521489acdaad8f,
title = "Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke",
abstract = "Background: It is unclear whether intravenous thrombolysis (IVT) with alteplase before endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results: Using multivariable regression, we evaluated the association of IVT+EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78{\%}) were treated with IVT+EVT, and 324 (22{\%}) with EVT alone. Patients treated with IVT+EVT had atrial fibrillation less often (16{\%} versus 44{\%}) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73{\%} versus 52{\%}) than those treated with EVT alone. Procedure time was shorter in the IVT+EVT group (median 62 versus 68 minutes). Nontransferred IVT+EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT+EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95{\%} CI: 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95{\%} CI: 0.40–0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions: In this observational study, patients treated with IVT+EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT.",
keywords = "endovascular treatment, large vessel occlusion, stroke, thrombectomy, thrombolysis",
author = "Vicky Chalos and LeCouffe, {Natalie E.} and Maarten Uyttenboogaart and Lingsma, {Hester F.} and Mulder, {Maxim J.H.L.} and Esmee Venema and Treurniet, {Kilian M.} and Omid Eshghi and {van der Worp}, {H. Bart} and {van der Lugt}, Aad and Roos, {Yvo B.W.E.M.} and Majoie, {Charles B.L.M.} and Dippel, {Diederik W.J.} and Bob Roozenbeek and Coutinho, {Jonathan M.} and {van Oostenbrugge}, {Robert J.} and {van Zwam}, {Wim H.} and Jelis Boiten and Vos, {Jan Albert} and Jansen, {Ivo G.H.} and Goldhoorn, {Robert Jan B.} and Schonewille, {Wouter J.} and Wermer, {Marieke J.H.} and {van Walderveen}, {Marianne A.A.} and Julie Staals and Jeannette Hofmeijer and Martens, {Jasper M.} and {Lycklama {\`a} Nijeholt}, {Geert J.} and Emmer, {Bart J.} and {de Bruijn}, {Sebastiaan F.} and {van Dijk}, {Lukas C.} and Lo, {Rob H.} and {van Dijk}, {Ewoud J.} and Boogaarts, {Hieronymus D.} and {de Kort}, {Paul L.M.} and Peluso, {Jo J.P.} and {van den Berg}, {Jan S.P.} and {van Hasselt}, {Boudewijn A.A.M.} and Aerden, {Leo A.M.} and Dallinga, {Ren{\'e} J.} and Schreuder, {Tobien H.C.M.L.} and Heijboer, {Roel J.J.} and Koos Keizer and Yo, {Lonneke S.F.} and {den Hertog}, {Heleen M.} and Sturm, {Emiel J.C.} and Sprengers, {Marieke E.S.} and Jenniskens, {Sjoerd F.M.} and Boers, {Anna M.M.} and Groot, {P. F.C.}",
year = "2019",
month = "6",
day = "4",
doi = "10.1161/JAHA.118.011592",
language = "English",
volume = "8",
journal = "Journal of the American Heart Association",
issn = "2047-9980",
publisher = "Wiley-Blackwell",
number = "11",

}

Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke. /.

In: Journal of the American Heart Association, Vol. 8, No. 11, e011592, 04.06.2019.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

AU - Chalos, Vicky

AU - LeCouffe, Natalie E.

AU - Uyttenboogaart, Maarten

AU - Lingsma, Hester F.

AU - Mulder, Maxim J.H.L.

AU - Venema, Esmee

AU - Treurniet, Kilian M.

AU - Eshghi, Omid

AU - van der Worp, H. Bart

AU - van der Lugt, Aad

AU - Roos, Yvo B.W.E.M.

AU - Majoie, Charles B.L.M.

AU - Dippel, Diederik W.J.

AU - Roozenbeek, Bob

AU - Coutinho, Jonathan M.

AU - van Oostenbrugge, Robert J.

AU - van Zwam, Wim H.

AU - Boiten, Jelis

AU - Vos, Jan Albert

AU - Jansen, Ivo G.H.

AU - Goldhoorn, Robert Jan B.

AU - Schonewille, Wouter J.

AU - Wermer, Marieke J.H.

AU - van Walderveen, Marianne A.A.

AU - Staals, Julie

AU - Hofmeijer, Jeannette

AU - Martens, Jasper M.

AU - Lycklama à Nijeholt, Geert J.

AU - Emmer, Bart J.

AU - de Bruijn, Sebastiaan F.

AU - van Dijk, Lukas C.

AU - Lo, Rob H.

AU - van Dijk, Ewoud J.

AU - Boogaarts, Hieronymus D.

AU - de Kort, Paul L.M.

AU - Peluso, Jo J.P.

AU - van den Berg, Jan S.P.

AU - van Hasselt, Boudewijn A.A.M.

AU - Aerden, Leo A.M.

AU - Dallinga, René J.

AU - Schreuder, Tobien H.C.M.L.

AU - Heijboer, Roel J.J.

AU - Keizer, Koos

AU - Yo, Lonneke S.F.

AU - den Hertog, Heleen M.

AU - Sturm, Emiel J.C.

AU - Sprengers, Marieke E.S.

AU - Jenniskens, Sjoerd F.M.

AU - Boers, Anna M.M.

AU - Groot, P. F.C.

PY - 2019/6/4

Y1 - 2019/6/4

N2 - Background: It is unclear whether intravenous thrombolysis (IVT) with alteplase before endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results: Using multivariable regression, we evaluated the association of IVT+EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT+EVT, and 324 (22%) with EVT alone. Patients treated with IVT+EVT had atrial fibrillation less often (16% versus 44%) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT+EVT group (median 62 versus 68 minutes). Nontransferred IVT+EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT+EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI: 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI: 0.40–0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions: In this observational study, patients treated with IVT+EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT.

AB - Background: It is unclear whether intravenous thrombolysis (IVT) with alteplase before endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results: Using multivariable regression, we evaluated the association of IVT+EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT+EVT, and 324 (22%) with EVT alone. Patients treated with IVT+EVT had atrial fibrillation less often (16% versus 44%) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT+EVT group (median 62 versus 68 minutes). Nontransferred IVT+EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT+EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI: 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI: 0.40–0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions: In this observational study, patients treated with IVT+EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT.

KW - endovascular treatment

KW - large vessel occlusion

KW - stroke

KW - thrombectomy

KW - thrombolysis

UR - http://www.scopus.com/inward/record.url?scp=85067315956&partnerID=8YFLogxK

U2 - 10.1161/JAHA.118.011592

DO - 10.1161/JAHA.118.011592

M3 - Article

C2 - 31140355

AN - SCOPUS:85067315956

VL - 8

JO - Journal of the American Heart Association

JF - Journal of the American Heart Association

SN - 2047-9980

IS - 11

M1 - e011592

ER -