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Abstract
Background and Objectives It is still uncertain that going direct to endovascular thrombectomy (EVT) leads to equivalent outcomes as bridging IV thrombolysis (IVT) in acute ischemic patients. This study aimed to explore whether the rate of ischemic core growth influenced the patient outcomes after bridging IVT vs direct EVT.
Methods This was a retrospective cohort study based on the International Stroke Perfusion Imaging Registry (INSPIRE). It selected acute ischemic stroke patients receiving perfusion CT within 4.5 hours of stroke onset. Patients who went direct to EVT were compared with those who received bridging treatment of IVT before EVT. Ischemic core growth rate was estimated by the acute ischemic core volume on perfusion CT divided by the time from stroke onset to perfusion CT, based on the assumption of a linear growth pattern of ischemic core. Core growth rate was stratified into fast (>15 mL/h) and slow (≤15 mL/h), based on its interaction with bridging IVT in predicting the primary outcome. The primary outcome was modified Rankin scale of 0–2 at 3 months. The secondary outcomes included successful thrombectomy reperfusion defined by modified Thrombolysis in Cerebral Infarction score of 2b–3 and time from groin puncture to reperfusion.
Results Of the 1,221 EVT patients in the INSPIRE, 323 patients were selected, of which 82 patients received direct EVT and 241 patients received bridging IVT. Bridging IVT was associated with a higher rate of good clinical outcome among patients with fast core growth (39% vs 7% for direct EVT, odds ratio [OR] 8.75 [1.96–39.1], p = 0.005), but the difference was not notable for patients with slow core growth (55% vs 55% for direct EVT, OR 1.00 [0.53–1.87], p = 0.989). In patients with fast core growth, the bridging and direct EVT patients showed no difference in the reperfusion rate (80% vs 76%, p = 0.616). However, patients who received bridging IVT were more likely to achieve reperfusion earlier (the median groin to reperfusion time of 63.0 vs 94.0 minutes, p = 0.005).
Discussion Patients with fast core growth were more likely to benefit from bridging IVT. This is likely because prior IVT facilitates clot removal and thus reduces time to reperfusion.
Glossary
- CTA=
- CT angiography;
- CTP=
- CT perfusion;
- EVT=
- endovascular thrombectomy;
- INSPIRE=
- International Stroke Perfusion Imaging Registry;
- IVT=
- IV thrombolysis;
- mTICI=
- modified TICI;
- NCCA=
- noncontrast CT;
- OR=
- odds ratio;
- PH=
- parenchymal hematoma;
- sICH=
- symptomatic intracranial hemorrhage;
- TICI=
- Thrombolysis in Cerebral Infarction
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Coinvestigators are listed in Appendix 2 at the end of the article.
Submitted and externally peer reviewed. The handling editor was Editor-in-Chief José Merino, MD, MPhil, FAAN.
Editorial, page 939
- Received September 27, 2022.
- Accepted in final form January 20, 2023.
- © 2023 American Academy of Neurology
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