Intravenous Thrombolysis Group Research Articles

MD3 - Cost-Effectiveness Analysis of Mechanical Thrombectomy With Revive SE® Versus Intravenous Thrombolysis for the Treatment of Acute Ischemic Stroke in China

Both intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) were recommended for treating acute ischemic stroke (AIS) by clinical guidelines. ReVive SE® is an innovative MT device with demonstrated clinical value, however, its economic evaluation in China is limited. The study aims to determine the cost-effectiveness of ReVive SE® versus IVT in AIS patients from a payer's perspective in China. A two-part model was developed to estimate the cost-effectiveness of ReVive SE® versus IVT. The short-term part (90 days) was a decision-tree that included three health states based on the modified Rankin Scale (mRS) score after treatment: independence (mRS=0-2), disability (mRS=3-5) and death (mRS=6). The long-term (lifetime) part was a Markov model that included four states: independence, disability, stroke recurrence, and death. Clinical efficacy, utility and cost data were obtained from Chinese ReVive SE® registry study and published literature. The model calculated quality-adjusted life years (QALYs) and total costs per patient. Costs and QALYs were discounted by 3.5% annually. Both one-way sensitivity analysis and probabilistic sensitivity analysis were conducted. The incremental cost-effectiveness ratios (ICERs) for ReVive SE® vs. IVT groups were ¥66,355/QALY, ¥39,062/QALY, and ¥35,305/QALY, respectively for 5-year, 15-year, and lifetime horizon. The ICER became lower than the recommended cost-effectiveness threshold (3 times of gross domestic product per capita, ¥161,940) beginning at the 1 year following the procedure till lifetime. Both one-way and probabilistic sensitivity analysis confirmed the robustness of the results. With the 3 times of gross domestic product threshold, ReVive SE ® is 87.46% cost-effective compared with IVT for lifetime horizon in the model. MT with ReVive SE® is a cost-effective treatment of AIS in China compared to IVT. This evidence supports the broad clinical application of MT with ReVive SE® over IVT. With caregivers’ costs unmeasured, ReVive SE® could be even more cost-effective.

Endovascular therapy versus thrombolysis in patients with large vessel occlusions within the anterior circulation aged ≥80 years

Background and purposeIn patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, the effectiveness of ET in...

Comparison of multimodal intra-arterial treatment versus intravenous thrombolysis for hypertensive patients with severe large vessel cerebral infarction

Since intravenous thrombolysis (IVT) is often associated with poor outcomes in hypertensive patients with severe acute cerebral infarction (ACI) due to occlusions of the internal carotid, basilar, or proximal middle...

Intravenous thrombolysis treatment compliance in patients with acute ischemic stroke in Zhengzhou University People’s Hospital

Objective To investigate the current status about the application of alteplase (rt-PA) for intravenous thrombolysis in acute ischemic stroke patients, and clarify the relevant factors affecting patients’ compliance of intravenous thrombolysis. Methods The acute ischemic stroke patients admitted in Department of Emergency, from January 2014 to December 2015 were recruited for study prospectively. After the patients with contraindications of thrombolysis were excluded, the eligible patients were divided into two groups, intravenous thrombolysis group (ITG) and non-intravenous thrombolysis group (NTG). Receiver operating characteristic curve(ROC)was used to determine the optimal cutoff point and the crucial NIHSS score of patients for decision on thrombolysis therapy. Results There were 230 patients with acute ischemic stroke occurred in the period of two years. Of 189 eligible patients, 33 refused the intravenous thrombolysis treatment (NTG) whereas 156 willing to take the intravenous thrombolysis treatment (ITG). The intravenous thrombolysis rate of eligible ischemic stroke patients reached to Henan Provincial People’s Hospital within the time window (4.5 hours) was 67.8% without contraindications. The results of the single-factor analysis for the patients of the two groups displayed that the differences in factors including age, baseline NIHSS score, limb weakness, hemiplegic paralysis, dysphasia, as well as dizziness were significant between two groups (t=2.578, P=0.047; U=157.221, P=0.000; χ2=26.702, P=0.000; χ2=9.069, P=0.003; χ2=7.381, P=0.007; χ2=28.636, P=0.000). The ROC analysis demonstrated the relationship between the baseline NIHSS score and the patients receiving intravenous thrombolysis. When NIHSS score<7, patients tended to refuse the treatment with intravenous thrombolysis (sensitivity 0.87, specificity 0.82). Among the patients receiving intravenous thrombolysis, the significant differences in intracranial hemorrhage rate, hospitalization mortality rate and 3-month mortality rate were not found between the patients with baseline NIHSS score≥7 and score<7 (1.9% vs. 3.9%, P= 0.662; 1.9% vs. 7.8%, P=0.168 and 3.8% vs. 11.7%, P=0.142, respectively). However a higher rate of favorable prognosis (3-month modified Rankin Scale score≤1) was observed in thrombolysis patients (75.5% vs. 41.7%, P=0.000). Conclusions Factors such as age, baseline NIHSS score, limb weakness, hemiplegic paralysis, dysphasia, as well as dizziness are supposed to be associated with patients’ compliance of intravenous thrombolysis. Key words: Brain infarction; Ischemic stroke; Tissue plasminogen activator; Thrombolysis

Clinical Outcomes of Patients with Acute Basilar Artery Occlusion in Brazil: An Observational Study

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) were proven safe and effective for anterior circulation proximal occlusions. However, the most appropriate recanalization strategy in patients with acute basilar artery occlusion (BAO) is still controversial. This study aimed to assess outcomes of patients with BAO at an academic stroke center in Brazil. This is a retrospective analysis of consecutive patients with BAO from a prospective stroke registry at Ribeirão Preto Medical School. Primary outcomes were mortality and favorable outcome (modified Rankin score [mRS] ≤3) at 90 days. After univariate analyses, multivariate logistic regressions were used to identify independent predictors of primary outcomes. Between August 2004 and December 2015, 63 (65% male) patients with BAO and median National Institutes of Health Stroke Scale (NIHSS) score of 31 (interquartile range: 19-36) were identified. Twenty-nine (46%) patients received no acute recanalization therapy, 15 (24%) received IVT, and 19 (30%) received EVT (68% treated with stent retrievers). Twenty-four (83%) patients treated conservatively died, and only 2 (7%) achieved an mRS less than or equal to 3. Among patients treated with acute recanalization therapies, 15 (44%) died, and 9 (26.5%) had a favorable outcome. On multivariate analysis, baseline systolic blood pressure (odds ratio [OR] = .97; 95% confidence interval [CI]: .95-0.99; P = .023), posterior circulation Alberta Stroke Program Early CT score (OR = .62; 95% CI: .41-0.94; P = .026), and successful recanalization (OR = .18; 95% CI: .04-0.71; P = .015) were independent predictors of lower mortality. Baseline NIHSS (OR = 1.40; 95% CI: 1.08-1.82; P = .012), prior use of statins (OR = .003; 95% CI: .001-0.28; P = .012), and successful recanalization (OR = .05; 95% CI: .001-0.27; P = .009) were independent predictors of favorable outcome. There was no significant difference between the IVT group and the EVT group on primary outcomes. BAO is associated with high morbidity and mortality in Brazil. Access to acute recanalization therapies may decrease mortality in those patients.

Safety of Early Carotid Endarterectomy after Intravenous Thrombolysis in Acute Ischemic Stroke

The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2days (range: 0-13). A subgroup of 6 patients underwent CEA within 24hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P=0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.

Efficacy comparison of three vascular recanalization in patients with acute vertebrobasilar occlusion

Objectives: To investigate the therapeutic effects of intravenous thrombolysis, intra-artery thrombolysis, mechanical thrombectomy on patients with acute vertebrobasilar occlusion. Methods: Retrospective analysis of clinical data of patients with acute vertebrobasilar occlusion, admitted to Huai'an First People's Hospital and Bingtuan Qishi Hospital from January 2014 to January 2016, was performed. According to different vascular recanalization, these patients were divided into intravenous thrombolysis group, intra-artery thrombolysis group and mechanical thrombectomy group. Clinical outcomes were compared among the three groups such as recanalization rates( modified thrombolysis in cerebral infarction[mTICI]≥2b), changes of NIHSS scores after 24 hours(scores decreased at least 4 points or complete resolution of symptoms), symptomatic cerebral hemorrhage rate(European Cooperative Acute Stroke Study Ⅱ standard) and modified Rankin scale(mRS) score improvement 3 months after treatment. Results: Among patients from mechanical thrombectomy group, the recanalization rate was 87.5%(28/32), 22 patients(68.8%)got good outcome according to the significant decrease of NIHSS scores, symptomatic intracranial hemorrhage occurred in 3 patient (9.4%), the rate of good prognosis(mRS≤2) at 3 months was 50.0% (16/32). In patients from intravenous thrombolysis group, the rate of recanalization was 34.8% (16/46), 12 patients(26.1%)got apparent decrease of NIHSS scores, symptomatic cerebral hemorrhage occurred in 14 patients(30.4%), the rate of good clinical outcome(mRS ≤2) at 3 months was 17.4%(8/46). Among patients from intra-arterial thrombolysis group, the recanalization rate was 53.3%(16/30), 12 patients(40.0%) got good outcome according to the significant decrease in NIHSS score, symptomatic intracranial hemorrhage occurred in 6 patients(20.0%), the rate of good prognosis(mRS≤2) at 3 months was 26.7%(8/30). The rate of complete recanalization and NIHSS score improvement at 24 hours were significantly higher in the mechanical thrombectomy group than the intravenous or intra-arterial thrombolysis group(χ(2)=21.324, P<0.001; χ(2)=14.162, P=0.001). The good outcome(mRS≤2) at 3 months was more frequent in the mechanical thrombectomy group than the intravenous or intra-arterial thrombolysis group (χ(2)=9.799, P=0.007). The differences of symptomatic intracranial hemorrhage rate among the three treatment groups were not statistically significant(χ(2)=5.035, P=0.081). Conclusion: As compared with the intravenous or intra-arterial thrombolysis, the mechanical thrombectomy has better efficiency and safety in the treatment of acute vertebrobasilar occlusion.

Efficacy of intravenous thrombolysis in acute ischemic stroke with hyperdense middle cerebral artery sign

Objective: To observe the efficacy and safety of recombinant tissue-type plasminogen activator (rtPA) intravenous thrombolysis (IVT) in the treatment of acute cerebral infarction with hyperdense middle cerebral artery sign (HMCAS). Methods: Acute cerebral infarction patients with HMCAS from July 2010 to November 2015 at the First Affiliated Hospital of Dalian Medical University were collected.These patients were divided into two groups depending on whether they received IVT or not.The Nation Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to evaluate early and long-time therapeutic effects.Efficacy and safety were compared between the two groups. Results: A total of 93 patients were eligible for the analysis, with 45 cases in IVT group and 48 cases in non-IVT group.As time went by, NIHSS score in IVT group showed significant downward trend than the non-IVT group.The rate of patients with good outcome in IVT group was higher than that in non-IVT group (P<0.05). The rate of hemorrhage transformation (HT) in IVT group and non-IVT group was 35.6% (16/45) and 10.4% (11/48), respectively, and the difference was statistically significant (P<0.05). While no statistically significant difference was found about the rate of symptomatic intracranial hemorrhage (sICH) (8.9% vs 2.1%, P>0.05) and mortality (33.3% vs 27.1%, P>0.05) between these two groups.Logistic regression analysis identified relativity between IVT treatment and good outcome (P<0.05), hemorrhage transformation (P<0.05), rather than mortality (P>0.05). Conclusions: Intravenous thrombolysis with rt-PA is an effective and safe treatment for most acute ischemic stroke patients with HMCAS and can promote early neurologic improvement and significantly improve long-term functional prognosis.Although Ⅳ thrombolysis can increase the risk of overall HT, it does not add risk in sICH and mortality.

Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke

Mechanical thrombectomy (MT) improves clinical outcomes in patients with acute ischemic stroke (AIS) caused by a large vessel occlusion. However, it is not known whether intravenous thrombolysis (IVT) is of added benefit in patients undergoing MT. To examine whether treatment with IVT before MT with a stent retriever is beneficial in patients undergoing MT. This post hoc analysis used data from 291 patients treated with MT included in 2 large, multicenter, prospective clinical trials that evaluated MT for AIS (Solitaire With the Intention for Thrombectomy performed from January 1, 2010, through December 31, 2011, and Solitaire Flow Restoration Thrombectomy for Acute Revascularization from January 1, 2010, through December 31, 2012). An independent core laboratory scored the radiologic outcomes in each trial. Patients were treated with IVT with tissue plasminogen activator followed by MT (IVT and MT group) with the use of a stent retriever or MT with a stent retriever alone (MT group). Successful reperfusion, functional independence (modified Rankin Scale score of 0-2) and mortality at 90 days, symptomatic intracranial hemorrhage, emboli to new territory, and vasospasm were compared. Of 291 patients included in the analysis, 160 (55.0%) underwent IVT and MT (mean [SD] age, 67 [13] years; 97 female [60.6%]), and 131 (45.0%) underwent MT alone (mean [SD] age, 69 [12] years; 71 [55.7%] female). Median Alberta Stroke Program Early CT Score at baseline was lower in the IVT and MT group (8 vs 9, P = .04). There was no statistically significant difference in the duration from symptom onset to groin puncture (254 minutes for the IVT and MT group vs 262 minutes for the MT group, P = .10). The number of passes, rate of successful reperfusion, functional independence at 90 days, mortality at 90 days, and emboli to new territory were also similar among groups. Symptomatic intracranial hemorrhage (1% vs 4%) and parenchymal hemorrhages type 1 (1% vs 3%) or type 2 (1% vs 2%) did not differ significantly (P = .25). Vasospasm occurred more often in patients who received IVT and MT vs MT alone (27% vs 14%, P = .006). In multivariate analysis, no statistically significant association was observed between IVT and MT vs MT alone for any of the outcomes. The results indicate that treatment of patients experiencing AIS due to a large vessel occlusion with IVT before MT does not appear to provide a clinical benefit over MT alone. A randomized clinical trial seems warranted. clinicaltrials.gov Identifiers: NCT01054560 and NCT01327989.

Investigation and analysis of the delay situation of thrombolysis treatment in hospital in patients with acute ischemic stroke

Objective To know the situation of time delay from the patients with ischemic stroke arrived the emergency to accepted the thrombolysis treatment, and analyze the related factors in order to put forward effective process optimization measures. Methods Totally 122 patients with acute ischemic stroke admitted into a Beijing grade A tertiary hospital who needed receive thrombolysis treatment from June 2014 to June 2015 were selected as the research object according to the purpose sampling method. Then we recorded the time in the whole process which were devided into 4 steps (arrived at the emergency department- obtained consultation of stroke physicians; obtained consultation of stroke physicians- arrived in CT chamber; arrived in CT chamber- got CT scan results; got CT scan results- accepted thrombolysis therapy). Results The time delayed in hospital of intravenous thrombolysis group and artery thrombolysis group were (114.95±29.48)min and (171.22±50.10)min. The step of biggest delta-T between the actual time and standard time of two groups were both from getting a CT scan results to accepting thrombolysis therapy. Conclusions The delay after getting a CT scan results is the most important reason of delay in hospital. Shorten the time of blood test, optimize the hospital management and perfect the construction of the green channel, can promote the situation of the delay in hospital, and, improve the efficiency of thrombolysis treatment. Key words: Acute ischemic stroke; Thrombolysis; Delay in hospita

Intravenous rtPA versus mechanical thrombectomy in acute ischemic stroke: A historical cohort in Joinville, Brazil.

Groundbreaking results concerning ischemic stroke (IS) hyperacute treatment worldwide were published in 2014 and 2015. We aimed to compare functional status after 3 months in patients treated with intra-arterial thrombectomy (IAT) and those treated with intravenous thrombolysis (IVT) alone in Joinville, Brazil.From the Joinville Stroke Registry, we extracted and compared all consecutive IVT patients treated with r-tPA within 4.5 h in the period 2009–2011 versus all consecutive IAT treated within 6 h with the Solitaire FR device plus IVT in the period 2012–2014.We registered 82 patients in the IVT group and 31 patients in the IAT group. At hospital admission, patients in the IAT group were significantly younger (p < 0.001), had a higher educational level (p = 0.001), had a slightly higher prevalence of atrial fibrillation (p = 0.057) and had more severe strokes measured by the NIH stroke scale (p = 0.011). After 90 days, 45% of patients in the IAT group and 27% in the IVT group were independent (0–1 points) according to the modified Rankin scale (adjusted odds ratio: 4.53; 95% CI: 1.22 to 16.75). Symptomatic hemorrhage was diagnosed in 10% of patients in both groups (p = 1.0). The 90-day case-fatality was 39% (32/82) in the IVT group and 26% (8/31) in the IAT group (p = 0.27). In this small cohort, a greater rate of functional independence was achieved in patients treated with IAT plus IVT, compared with patients treated with IVT lysis alone. Our “real-world” findings are consistent with results of controlled, randomized clinical trials.

Intravenous Thrombolysis Facilitates Successful Recanalization with Stent-Retriever Mechanical Thrombectomy in Middle Cerebral Artery Occlusions

Several factors influence the outcome after acute ischemic stroke secondary to proximal occlusions of cerebral vessels. Among others, noneligibility for intravenous thrombolysis (IVT) and incomplete revascularization have been identified as predictors of unfavorable outcome. The aim of this study was to investigate whether concomitant IVT influences the revascularization efficacy in mechanical thrombectomy (MT). This study conducted a retrospective analysis of all consecutive patients presenting with an anterior circulation stroke due to large-artery occlusion with imaging evidence who were treated with MT between July 2012 and December 2013 at 2 high-volume stroke centers. Imaging data were regraded and re-evaluated according to the modified Treatment in Cerebral Ischemia scale and its respective vessel occlusion site definitions. Clinical end points included National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale; imaging and procedural measures were technical end points. We identified 93 patients who presented with an occlusion of the middle cerebral artery (MCA): of these patients, 66 (71%) received IVT. We did not find statistically significant differences in the baseline NIHSS score, time from symptom onset to groin puncture, and age when comparing the IVT group with the non-IVT group. The rate of successful recanalizations (modified Treatment in Cerebral Ischemia score ≥ 2b) was significantly higher in patients with MCA occlusion and concomitant IVT (P = .01). Stepwise logistic regression identified IVT and thrombus length as predictive factors for successful mechanical recanalization (P = .004, P = .002). IVT and thrombus length are predictive factors for a successful recanalization in MT for acute ischemic stroke with underlying MCA occlusion.

Acute Ischemic Stroke Endovascular Treatment of Patients With Large Vessel Occlusions / Akūta Cerebrāla Infarkta Endovaskulāra Ārstēšana Pacientiem ar Maģistrālo Artēriju Oklūzijām

Abstract Mechanical thrombectomy as an active treatment method has recently been chosen for patients with large artery occlusions and thrombolysis beyond a time window. The aim of our study was to evaluate the results of endovascular treatment in patients with proximal vessel occlusion, compare this group with the intravenous thrombolysis group, and to identify possible criteria of active treatment. The prospective study included 81 patients hospitalised in the Pauls Stradiņš Clinical University Hospital due to acute ischemic stroke; 48 of them received mechanical thrombectomy and 33 - intravenous thrombolysis. Thrombectomy (TE) was performed using Solitaire FR stent retrievers. The NIHSS score was used for evaluation of early therapy results and mRS (modified Rankin Scale) was used for late therapy results. ASPECTS was used to define the lesion size using imaging on admission and after treatment. Median NIHSS on admission was higher in the TE group - 16 (range 12 to 19) than in the TL group - 12 (range 8 to 15) (p &lt; 0.05). Ninety days after treatment, mRS (0-2) was seen in 67% of patients in the TE group (n = 29), and 34% of patients in the TL group (n = 9) patients (p &lt; 0.05). Median ASPECTS was lower in TE group - 5, in comparison to the TL group - 7 (p &lt; 0.01) Mortality frequency was higher in the TL group (p &gt; 0.05). Frequency of symptomatic intracerebral haemorrhages was similar in the groups. Mechanical thrombectomy can achieve better late functional outcome than thrombolysis in a selected patients group.

Efficacy and Safety of Intravenous Thrombolysis for the Treatment of Acute Ischemic Stroke Patients with Saccular Intracranial Aneurysms of ≤3 mm

To explore the effectiveness and safety of intravenous thrombolysis (IVT) using recombinant tissue plasminogen activator in treating acute ischemic stroke patients with concomitant intracranial aneurysms (IA) of ≤3mm. Clinical data of patients who were treated in Tianjin Huanhu Hospital from June 2012 to September 2013 were retrospectively analyzed. Patients were divided into the following groups: (a) IVT group, in which there were 30 acute ischemic stroke patients with IA of ≤3mm and 30 patients without aneurysms; and (b) IA group, in which there were 30 patients who did not receive IVT and 30 patients who received IVT. The incidence of intracranial hemorrhage, case-fatality, and good outcome rate was compared within these two groups. Inside the IVT group, the incidence of systematic intracranial hemorrhage and case-fatality showed no significant differences between patients with concomitant IA and those without IA. The 3-month good outcome rate was also not significantly different (24 [80.0%] vs. 27 [90%]; P=0.278). In IA group, patients who had received IVT showed significantly superior good outcome rate than those who had not received IVT (24 [80.0%] vs. 16 [53.3%]; P=0.028).The incidence of intracranial hemorrhage and case-fatality rate were not significantly different between these two subgroups as well. IVT is effective and safe method for the treatment of acute ischemic stroke patients with saccular IA of ≤3mm.

Abstract T P23: Endovascular Treatment of Stroke in Elderly Patients: Comparison With Conventional Thrombolysis and Best Medical Treatment

Background and Purpose: Elderly patients have often been excluded from randomized stroke trials. The benefit of endovascular treatment of stroke in these patients remains uncertain. We sought to evaluate the outcomes of elderly patients treated endovascularly compared to those treated with conventional thrombolysis or best medical therapy. Methods: We retrospectively reviewed all stroke patients admitted to our center between 2008-2011. We included all patients age 75 or older with large vessel occlusion presenting within 8 hours of stroke onset. We evaluated outcomes at discharge including modified rankin score (mRS) and mortality as well as symptomatic intracerebral hemorrhage (sICH) within 24 hours for patients receiving endovascular treatment (EVT) with or without conventional thrombolysis , intravenous thrombolysis (IVT) or best medical treatment (BMT). Good outcome was defined as mRS of 3 or less at discharge. Results: A total of 91 patients met the inclusion criteria. 41 patients underwent EVT, 19 received IVtpa, and 31 BMT. Baseline NIHSS was not significantly different between the groups (17 SD 7, 16 SD 5, 14 SD 8 respectively). There was no difference in good outcomes between patients undergoing EVT compared to BMT (unadjusted OR 1.46, 95% CI 0.44-4.9), IVT compared to BMT (OR 2.4, 95% CI 0.62-9.36), or EVT compared to IVT (OR 0.61, 95% CI 0.18-2.06). There was no difference in mortality for the EVT, IVT, and BMT groups (22%, 26%, and 16% respectively, chi square p=0.79 for intergroup differences). Similarly there was no difference in rates of sICH 12%, 11%, and 3% p=0.41. Conclusion: Despite similar mortality and cerebral hemorrhage rates, we found no difference in good outcome for elderly patients treated with endovascular therapy or intravenous thrombolysis compared to best medical treatment within 8 hours of stroke onset. Larger studies are needed to clarify the role of intervention in elderly stroke patients.

O-005 The Price Is Right - A Cost-Effective Analysis Of Endovascular Therapy And Intravenous Thrombolysis For Large Vessel Strokes

BackgroundCost-effectiveness is integral in judging a treatment’s impact on healthcare. While endovascular therapy may yield better outcomes versus intravenous thrombolysis, the potential benefit is lost if the cost is prohibitive....

Abstract TP5: Comparison of Primary Intraarterial Thrombectomy and Intravenous Thrombolysis Bridging with Intraarterial Thrombectomy for Acute Ischemic Stroke

Background and purpose: It is not well-known whether intravenous thrombolysis (IVT) bridging with intraarterial mechanical thrombectomy (IAT) is more beneficial than primary IAT presenting within 3 hours after acute ischemic stroke. We assessed the safety and benefit of primary IAT in clinical outcomes by the comparison with bridging IVT-IAT. Methods: Clinical data of 65 patients (43; primary IVT, 22; primary IAT), who were underwent thrombolysis for the acute internal carotid (ICA) and/or middle cerebral (MCA) artery occlusions within 3hours from the symptom onset, were evaluated. IAT was performed using retrievable intracranial stent to remove thrombus impacted within ICA or MCA. Recanalization rate and hemorrhagic transformation after thrombectomy, and modified Rankin scale (mRS) checked at discharge and 3 months after discharge were compared between patients received primary IAT or bridging IVT-IAT. Results: Among primary IVT group, only 6 (14%) showed symptom improvement after IVT. In the other 37 patients, 26 patients were underwent additional IAT (bridging IVT-IAT group). Primary IAT and bridging IVT-IAT groups showed similar recanlization rate (IVT-IAT; 85%, IAT; 82%, p =0.548) and symptomatic intracerebral hemorrhage rate (IVT-IAT; 3.8%, IAT; 0%, p =0.421). The rate of favorable clinical outcome (mRS 0-2) was not different at discharge (IVT; 30%, IAT; 32%, p =0.556) and 3 months (IAT; 40%, IAT; 46%, p =0.472) after discharge in both groups. Conclusions: In conclusion, the safety and clinical outcome of primary IAT was not inferior to bridging IVT-IAT for large intracerebral artery occlusions. This study suggested primary IAT, when it can be accomplished promptly, should be considered as a treatment within 3 hours.

Feasibility and Safety of Magnetic Resonance Imaging-Based Thrombolysis in Patients with Stroke on Awakening: Initial Single-Centre Experience

Up to 25% of all acute ischaemic strokes occur during sleep. Because of the unclear time window, patients with stroke on awakening are usually not considered for acute therapy and excluded from most acute treatment trials. To evaluate the feasibility of magnetic resonance imaging-based intravenous thrombolysis in patients with stroke on awakening in a routine clinical setting. Forty-five patients with stroke on awakening clinically qualifying for intravenous thrombolysis and presenting within 6 h after symptom recognition were admitted to our institution between October 2006 and May 2008. Following an institutional protocol, patients received magnetic resonance imaging as a first-line imaging modality and were offered mismatch-based thrombolysis whenever possible. Baseline demographic data, clinical, laboratory and imaging findings were analysed. Outcome was assessed using the modified Rankin Scale score at 3 months. Magnetic resonance imaging screening was feasible in 43/45 patients (96%). After screening, 10 patients (22%) were treated with intravenous thrombolysis. There were no differences between treated and untreated patients regarding cardiovascular risk factors, stroke aetiology, previous prophylactic treatment and symptom recognition to door time or door to imaging time. Outcome was comparable in both groups despite a trend towards more severe strokes in the intravenous thrombolysis group. Only one asymptomatic and no symptomatic haemorrhage were observed. Our data demonstrate that magnetic resonance imaging-based thrombolysis is feasible and possibly safe in patients with stroke on awakening (SOA). Randomised clinical trials for patients with stroke on awakening are needed to further test the safety and efficacy of intravenous thrombolysis in this patient group. The results of our study may help to initiate and design such studies.

Intra-Arterial vs Intra-Venous Thrombolysis for Anterior Cerebral Occlusion

The safety and effectiveness of intra-arterial thrombolysis (IAT) in comparison to intravenous thrombolysis (IVT) for the treatment of ischemic stroke is uncertain. Our study aims to assess and compare IAT to IVT for clinically relevant outcomes in patients with occlusion of the anterior cerebral circulation. Patients with acute ischemic stroke were enrolled for either treatment; those whose symptoms occurred within 4.5 hrs after stroke were treated with IVT, whereas those who presented < 4.5 hrs but had contraindications to IVT or presented between 4.5 and 6 hrs were treated with IAT. Evaluated endpoints included: disability at 90 days as measured by the modified Rankin Scale (mRS), incidence of mortality, and incidence of symptomatic intracranial haemorrhage. 78 patients with anterior cerebral circulation occlusion were included in the study (55 in IVT, 23 in IAT). After 90 days, 82.6% patients treated with IAT reached independence in comparison to 56.4% in the IVT group (P = 0.028, RR = 2.66, 95% CI: 1.10-7.04). The incidence of all intracranial haemorrhages in the IAT and IVT groups respectively were 30.4% and 12.7% (P = 0.103, RR = 2.391, 95% CI: 0.946-6.047); symptomatic intracranial haemorrhage occurred in 8.7% and 9.1% of patients (P = 1.00, RR = 0.957, 95% CI: 0.200-4.579), and mortality in 8.7% and 16.4% (P = 0.492, RR = 1.882, 95% CI: 0.440-8.045). Results suggest that IAT is more effective than IVT in allowing patients to achieve independence. While inconclusive, the safety of IAT within 6 hrs is comparable to IVT within 4.5 hrs.

Stent-Assisted Endovascular Thrombolysis Versus Intravenous Thrombolysis in Internal Carotid Artery Dissection With Tandem Internal Carotid and Middle Cerebral Artery Occlusion

To the Editor: We have read the exciting article entitled “Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion.”1 The authors compared 4 patients who underwent intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator administered according to National Institute of Neurological Disorders and Stroke (NINDS) guidelines with 6 patients who were treated with an IV bolus of the glycoprotein (GP) IIb/IIIa antagonist abciximab (0.25 mg/kg body weight) and carotid stenting followed by mechanical thrombectomy in 5 cases and intra-arterial thrombolysis with 40 mg recombinant tissue plasminogen activator in the remaining case.1 Three-month outcome was worse in the IVT group …