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Abstract
Objective In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients.
Methods Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0–2 at 3 months], favorable functional outcome [mRS of 0–1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score–matched analyses were performed.
Results A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02–2.99) and functional improvement (common OR 1.64; 95% CI 1.05–2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26–0.96).
Conclusions This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial.
Classification of evidence This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.
Glossary
- AIS=
- acute ischemic stroke;
- ASPECTS=
- Alberta Stroke Program Early CT Score;
- CI=
- confidence interval;
- cOR=
- common odds ratio;
- ELVO=
- emergent large vessel occlusion;
- ESCAPE=
- Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke;
- FFO=
- favorable functional outcome;
- FI=
- functional independence;
- INT=
- infarct in a new previously unaffected territory;
- IRB=
- institutional review board;
- IVT=
- IV thrombolysis;
- MCA=
- middle cerebral artery;
- mRS=
- modified Rankin Scale;
- MT=
- mechanical thrombectomy;
- mTICI=
- modified Thrombolysis in Cerebral Infarction;
- NIHSS=
- NIH Stroke Scale;
- OR=
- odds ratio;
- PSM=
- propensity score matching;
- sICH=
- symptomatic intracranial hemorrhage;
- STAR=
- Solitaire FR Thrombectomy for Acute Revascularisation;
- SWIFT=
- Solitaire FR with the Intention for Thrombectomy;
- tPA=
- tissue plasminogen activator
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.
Editorial, page 673
Class of Evidence: NPub.org/coe
- Received August 7, 2017.
- Accepted in final form December 27, 2017.
- © 2018 American Academy of Neurology
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Letters: Rapid online correspondence
- Author response: Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion
- Reader response: Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion
- Pre-procedural thrombolysis may mitigate new infarcts and deficits in unexpectedly challenging thrombectomies
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