Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry.

Ilko L Maier,Daniel Behme,Mathias Bähr,Andreas Leha,Marios-Nikos Psychogios,Ibrahim Allam,Jan Liman,Mostafa Badr,Amelie Hesse,Ala Jamous

doi:10.3389/fneur.2021.649108

Abstract

Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone.Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days.Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, −0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate −0.350, 95% CI, −0.680; −0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI −0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864).Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.

Highlights

Endovascular treatment (EVT) of large vessel occlusion stroke (LVOS) has been shown to be highly effective and superior to intravenous thrombolysis (IVT) alone in multiple studies [1,2,3]
Patients with bridging-IVT were more likely to live at home without nursing, while the percentage of patients living in a nursing home was distributed
Alberta stroke programme early CT score (ASPECTS) was higher in the bridging group (9 vs. 8, p < 0.001); there were no differences in adverse events between both groups, including any kind of intracerebral hemorrhage (Supplementary Table 1)

Summary

Introduction

Endovascular treatment (EVT) of large vessel occlusion stroke (LVOS) has been shown to be highly effective and superior to intravenous thrombolysis (IVT) alone in multiple studies [1,2,3]. Within the HERMES trials, most patients received IVT prior to endovascular treatment (MrClean 87%; ESCAPE 72%) [1]. The conclusion of these trails to date is that IVT prior to thrombectomy is safe and still should be the standard of care. Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone.

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