Intravenous thrombolysis before thrombectomy for acute ischaemic stroke

Abstract

Before endovascular therapy, patients with ischaemic stroke due to occlusion of large arteries were treated with only intravenous thrombolysis, specifically alteplase. Intravenous thrombolysis recanalised about 25% of occluded large arteries, resulting in fewer than 30% of patients achieving functional independence (modified Rankin Score [mRS] 0–2) at 90 days. 1 Menon BK Al-Ajlan FS Najm M et al. Association of clinical, imaging, and thrombus characteristics with recanalization of visible intracranial occlusion in patients with acute ischemic stroke. JAMA. 2018; 320: 1017-1026 Crossref PubMed Scopus (117) Google Scholar In 2015, second-generation thrombectomy devices, in combination with intravenous thrombolysis, were proven to recanalise about 70–80% of arteries and improve rates of functional independence by 20–30% compared with intravenous thrombolysis alone. 2 Goyal M Menon BK van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387: 1723-1731 Summary Full Text Full Text PDF PubMed Scopus (3448) Google Scholar Some in the field began to ask if intravenous thrombolysis is even necessary for these patients. Intravenous thrombolysis can delay the more often definitive therapy of endovascular therapy. Moreover, intravenous thrombolysis could increase symptomatic intracerebral haemorrhage, or distal migration of thrombi, rendering them inaccessible to thrombectomy. Intravenous thrombolysis certainly incurs substantial cost. 3 de Souza AC Sebastian IA Zaidi WAW et al. Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability, and coverage. Int J Stroke. 2022; (published online March 18.)https://doi.org/10.1177/17474930221082446 Crossref PubMed Scopus (2) Google Scholar Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trialThrombectomy alone was not shown to be non-inferior to intravenous alteplase plus thrombectomy and resulted in decreased reperfusion rates. These results do not support omitting intravenous alteplase before thrombectomy in eligible patients. Full-Text PDF Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trialWe did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment. Full-Text PDF