Abstract
Background and Objectives: Pretreatment with intravenous thrombolysis (IVT) is still recommended in all eligible acute ischemic stroke patients with large-vessel occlusion before mechanical thrombectomy (MTE). However, the added value and safety of bridging therapy versus direct MTE remains controversial. We aimed at evaluating the influence of r-tPA dose level in patients with middle cerebral artery (MCA) occlusion treated with MTE. Materials and Methods: We prospectively compared clinical and radiological outcomes in 38 bridging patients, with 65 receiving direct MTE for MCA stroke admitted to Vilnius University Hospital Santaros Clinics. Following our protocol, r-tPA infusion was stopped just before MTE in the operating room. Therefore, we divided all bridging patients into three groups according to the amount of r-tPA they received: bolus, partial dose or full dose. Functional independence at 90 days was assessed by a modified Rankin Scale score, i.e., from 0–2. The safety outcomes included 90-day mortality and any intracerebral hemorrhage (ICH). Results: Baseline characteristics and functional outcome at 90 days did not differ between the bridging and direct MTE groups. Shorter MTE procedure and hospitalization time (p = 0.025 and p = 0.036, respectively) were observed in the direct MTE group. An IVT treatment subgroup analysis showed higher rates of symptomatic ICH (p < 0.001) and longer intervals between imaging to MTE (p = 0.005) in the full r-tPA dose group. Conclusions: In patients with an MCA stroke, direct MTE seems to be a safe and equally effective as bridging therapy. The optimal r-tPA dose remains unclear. Randomized trials are needed to accurately evaluate the added value of r-tPA in patients treated with MTE.
Highlights
Since the 2015 update of the American Heart Association/American Stroke Association guidelines, the pretreatment with intravenous thrombolysis (IVT) has been recommended in all eligible acute ischemic stroke patients with large-vessel occlusion (LVO) before mechanical thrombectomy (MTE) [1].the added value and safety of pretreatment with IVT before MTE in patients considered for MTE remains controversial [2,3]
One of them has suggested that bridging therapy (BT) patients had better functional outcomes, lower mortality, higher rates of successful recanalization and equal odds of symptomatic intracerebral hemorrhage compared with patients who received direct MTE [11]
One hundred and three patients were divided into groups according to the treatment they received: 38 were treated with bridging therapy intravenous thrombolysis and mechanical thrombectomy, and 65 were treated with direct mechanical thrombectomy alone
Summary
Since the 2015 update of the American Heart Association/American Stroke Association guidelines, the pretreatment with intravenous thrombolysis (IVT) has been recommended in all eligible acute ischemic stroke patients with large-vessel occlusion (LVO) before mechanical thrombectomy (MTE) [1].the added value and safety of pretreatment with IVT before MTE (bridging therapy) in patients considered for MTE remains controversial [2,3]. Since the 2015 update of the American Heart Association/American Stroke Association guidelines, the pretreatment with intravenous thrombolysis (IVT) has been recommended in all eligible acute ischemic stroke patients with large-vessel occlusion (LVO) before mechanical thrombectomy (MTE) [1]. In all randomized control trials (RCTs) showing MTE superiority to the best medical treatment (with and without IVT) in anterior circulation ischemic stroke patients with LVO, all IVT-eligible patients received IVT before undergoing. There are no RCTs to compare the outcomes after complete vs partial tPA IVT during bridging therapy (BT). Pretreatment with intravenous thrombolysis (IVT) is still recommended in all eligible acute ischemic stroke patients with large-vessel occlusion before mechanical thrombectomy (MTE). The safety outcomes included 90-day mortality and any intracerebral hemorrhage (ICH)
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