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Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion

IMPORTANCE: Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. OBJECTIVE: To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute isch...

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Autores principales: Faizy, Tobias D., Broocks, Gabriel, Heit, Jeremy J., Kniep, Helge, Flottmann, Fabian, Meyer, Lukas, Sporns, Peter, Hanning, Uta, Kaesmacher, Johannes, Deb-Chatterji, Milani, Vollmuth, Philipp, Lansberg, Maarten G., Albers, Gregory W., Fischer, Urs, Wintermark, Max, Thomalla, Götz, Fiehler, Jens, Winkelmeier, Laurens
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10152307/
https://www.ncbi.nlm.nih.gov/pubmed/37126350
http://dx.doi.org/10.1001/jamanetworkopen.2023.10213
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author Faizy, Tobias D.
Broocks, Gabriel
Heit, Jeremy J.
Kniep, Helge
Flottmann, Fabian
Meyer, Lukas
Sporns, Peter
Hanning, Uta
Kaesmacher, Johannes
Deb-Chatterji, Milani
Vollmuth, Philipp
Lansberg, Maarten G.
Albers, Gregory W.
Fischer, Urs
Wintermark, Max
Thomalla, Götz
Fiehler, Jens
Winkelmeier, Laurens
author_facet Faizy, Tobias D.
Broocks, Gabriel
Heit, Jeremy J.
Kniep, Helge
Flottmann, Fabian
Meyer, Lukas
Sporns, Peter
Hanning, Uta
Kaesmacher, Johannes
Deb-Chatterji, Milani
Vollmuth, Philipp
Lansberg, Maarten G.
Albers, Gregory W.
Fischer, Urs
Wintermark, Max
Thomalla, Götz
Fiehler, Jens
Winkelmeier, Laurens
author_sort Faizy, Tobias D.
collection PubMed
description IMPORTANCE: Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. OBJECTIVE: To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS: Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry–Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. INTERVENTIONS: Mechanical thrombectomy with or without IVT. MAIN OUTCOMES AND MEASURES: Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. RESULTS: After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). CONCLUSIONS AND RELEVANCE: These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
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spelling pubmed-101523072023-05-03 Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion Faizy, Tobias D. Broocks, Gabriel Heit, Jeremy J. Kniep, Helge Flottmann, Fabian Meyer, Lukas Sporns, Peter Hanning, Uta Kaesmacher, Johannes Deb-Chatterji, Milani Vollmuth, Philipp Lansberg, Maarten G. Albers, Gregory W. Fischer, Urs Wintermark, Max Thomalla, Götz Fiehler, Jens Winkelmeier, Laurens JAMA Netw Open Original Investigation IMPORTANCE: Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. OBJECTIVE: To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS: Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry–Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. INTERVENTIONS: Mechanical thrombectomy with or without IVT. MAIN OUTCOMES AND MEASURES: Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. RESULTS: After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). CONCLUSIONS AND RELEVANCE: These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment. American Medical Association 2023-05-01 /pmc/articles/PMC10152307/ /pubmed/37126350 http://dx.doi.org/10.1001/jamanetworkopen.2023.10213 Text en Copyright 2023 Faizy TD et al. JAMA Network Open. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an open access article distributed under the terms of the CC-BY-NC-ND License.
spellingShingle Original Investigation
Faizy, Tobias D.
Broocks, Gabriel
Heit, Jeremy J.
Kniep, Helge
Flottmann, Fabian
Meyer, Lukas
Sporns, Peter
Hanning, Uta
Kaesmacher, Johannes
Deb-Chatterji, Milani
Vollmuth, Philipp
Lansberg, Maarten G.
Albers, Gregory W.
Fischer, Urs
Wintermark, Max
Thomalla, Götz
Fiehler, Jens
Winkelmeier, Laurens
Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
title Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
title_full Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
title_fullStr Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
title_full_unstemmed Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
title_short Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
title_sort association between intravenous thrombolysis and clinical outcomes among patients with ischemic stroke and unsuccessful mechanical reperfusion
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10152307/
https://www.ncbi.nlm.nih.gov/pubmed/37126350
http://dx.doi.org/10.1001/jamanetworkopen.2023.10213
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