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Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data

BACKGROUND: Achieving the best possible reperfusion is a key determinant of clinical outcome after mechanical thrombectomy (MT). However, data on the safety and efficacy of intra-arterial (IA) fibrinolytics as an adjunct to MT with the intention to improve reperfusion are sparse. METHODS: We perform...

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Autores principales: Kaesmacher, Johannes, Meinel, Thomas Raphael, Kurmann, Christoph, Zaidat, Osama O, Castonguay, Alicia C, Zaidi, Syed F, Mueller-Kronast, Nils, Kappelhof, Manon, Dippel, Diederik W J, Soudant, Marc, Bracard, Serge, Hill, Michael D, Goyal, Mayank, Strbian, Daniel, Heiferman, Daniel M, Ashley, William, Anadani, Mohammad, Spiotta, Alejandro M, Dobrocky, Tomas, Piechowiak, Eike I, Arnold, Marcel, Goeldlin, Martina, Seiffge, David, Mosimann, Pascal J, Mordasini, Pasquale, Gralla, Jan, Fischer, Urs
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8606438/
https://www.ncbi.nlm.nih.gov/pubmed/33514609
http://dx.doi.org/10.1136/neurintsurg-2020-016680
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author Kaesmacher, Johannes
Meinel, Thomas Raphael
Kurmann, Christoph
Zaidat, Osama O
Castonguay, Alicia C
Zaidi, Syed F
Mueller-Kronast, Nils
Kappelhof, Manon
Dippel, Diederik W J
Soudant, Marc
Bracard, Serge
Hill, Michael D
Goyal, Mayank
Strbian, Daniel
Heiferman, Daniel M
Ashley, William
Anadani, Mohammad
Spiotta, Alejandro M
Dobrocky, Tomas
Piechowiak, Eike I
Arnold, Marcel
Goeldlin, Martina
Seiffge, David
Mosimann, Pascal J
Mordasini, Pasquale
Gralla, Jan
Fischer, Urs
author_facet Kaesmacher, Johannes
Meinel, Thomas Raphael
Kurmann, Christoph
Zaidat, Osama O
Castonguay, Alicia C
Zaidi, Syed F
Mueller-Kronast, Nils
Kappelhof, Manon
Dippel, Diederik W J
Soudant, Marc
Bracard, Serge
Hill, Michael D
Goyal, Mayank
Strbian, Daniel
Heiferman, Daniel M
Ashley, William
Anadani, Mohammad
Spiotta, Alejandro M
Dobrocky, Tomas
Piechowiak, Eike I
Arnold, Marcel
Goeldlin, Martina
Seiffge, David
Mosimann, Pascal J
Mordasini, Pasquale
Gralla, Jan
Fischer, Urs
author_sort Kaesmacher, Johannes
collection PubMed
description BACKGROUND: Achieving the best possible reperfusion is a key determinant of clinical outcome after mechanical thrombectomy (MT). However, data on the safety and efficacy of intra-arterial (IA) fibrinolytics as an adjunct to MT with the intention to improve reperfusion are sparse. METHODS: We performed a PROSPERO-registered (CRD42020149124) systematic review and meta-analysis accessing MEDLINE, PubMed, and Embase from January 1, 2000 to January 1, 2020. A random-effect estimate (Mantel-Haenszel) was computed and summary OR with 95% CI were used as a measure of added IA fibrinolytics versus control on the risk of symptomatic intracranial hemorrhage (sICH) and secondary endpoints (modified Rankin Scale ≤2, mortality at 90 days). RESULTS: The search identified six observational cohort studies and three observational datasets of MT randomized-controlled trial data reporting on IA fibrinolytics with MT as compared with MT alone, including 2797 patients (405 with additional IA fibrinolytics (100 urokinase (uPA), 305 tissue plasminogen activator (tPA)) and 2392 patients without IA fibrinolytics). Of 405 MT patients treated with additional IA fibrinolytics, 209 (51.6%) received prior intravenous tPA. We did not observe an increased risk of sICH after administration of IA fibrinolytics as adjunct to MT (OR 1.06, 95% CI 0.64 to 1.76), nor excess mortality (0.81, 95% CI 0.60 to 1.08). Although the mode of reporting was heterogeneous, some studies observed improved reperfusion after IA fibrinolytics. CONCLUSION: The quality of evidence regarding peri-interventional administration of IA fibrinolytics in MT is low and limited to observational data. In highly selected patients, no increase in sICH was observed, but there is large uncertainty.
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spelling pubmed-86064382021-12-03 Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data Kaesmacher, Johannes Meinel, Thomas Raphael Kurmann, Christoph Zaidat, Osama O Castonguay, Alicia C Zaidi, Syed F Mueller-Kronast, Nils Kappelhof, Manon Dippel, Diederik W J Soudant, Marc Bracard, Serge Hill, Michael D Goyal, Mayank Strbian, Daniel Heiferman, Daniel M Ashley, William Anadani, Mohammad Spiotta, Alejandro M Dobrocky, Tomas Piechowiak, Eike I Arnold, Marcel Goeldlin, Martina Seiffge, David Mosimann, Pascal J Mordasini, Pasquale Gralla, Jan Fischer, Urs J Neurointerv Surg Ischemic Stroke BACKGROUND: Achieving the best possible reperfusion is a key determinant of clinical outcome after mechanical thrombectomy (MT). However, data on the safety and efficacy of intra-arterial (IA) fibrinolytics as an adjunct to MT with the intention to improve reperfusion are sparse. METHODS: We performed a PROSPERO-registered (CRD42020149124) systematic review and meta-analysis accessing MEDLINE, PubMed, and Embase from January 1, 2000 to January 1, 2020. A random-effect estimate (Mantel-Haenszel) was computed and summary OR with 95% CI were used as a measure of added IA fibrinolytics versus control on the risk of symptomatic intracranial hemorrhage (sICH) and secondary endpoints (modified Rankin Scale ≤2, mortality at 90 days). RESULTS: The search identified six observational cohort studies and three observational datasets of MT randomized-controlled trial data reporting on IA fibrinolytics with MT as compared with MT alone, including 2797 patients (405 with additional IA fibrinolytics (100 urokinase (uPA), 305 tissue plasminogen activator (tPA)) and 2392 patients without IA fibrinolytics). Of 405 MT patients treated with additional IA fibrinolytics, 209 (51.6%) received prior intravenous tPA. We did not observe an increased risk of sICH after administration of IA fibrinolytics as adjunct to MT (OR 1.06, 95% CI 0.64 to 1.76), nor excess mortality (0.81, 95% CI 0.60 to 1.08). Although the mode of reporting was heterogeneous, some studies observed improved reperfusion after IA fibrinolytics. CONCLUSION: The quality of evidence regarding peri-interventional administration of IA fibrinolytics in MT is low and limited to observational data. In highly selected patients, no increase in sICH was observed, but there is large uncertainty. BMJ Publishing Group 2021-12 2021-01-29 /pmc/articles/PMC8606438/ /pubmed/33514609 http://dx.doi.org/10.1136/neurintsurg-2020-016680 Text en © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. https://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ (https://creativecommons.org/licenses/by-nc/4.0/) .
spellingShingle Ischemic Stroke
Kaesmacher, Johannes
Meinel, Thomas Raphael
Kurmann, Christoph
Zaidat, Osama O
Castonguay, Alicia C
Zaidi, Syed F
Mueller-Kronast, Nils
Kappelhof, Manon
Dippel, Diederik W J
Soudant, Marc
Bracard, Serge
Hill, Michael D
Goyal, Mayank
Strbian, Daniel
Heiferman, Daniel M
Ashley, William
Anadani, Mohammad
Spiotta, Alejandro M
Dobrocky, Tomas
Piechowiak, Eike I
Arnold, Marcel
Goeldlin, Martina
Seiffge, David
Mosimann, Pascal J
Mordasini, Pasquale
Gralla, Jan
Fischer, Urs
Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
title Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
title_full Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
title_fullStr Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
title_full_unstemmed Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
title_short Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
title_sort safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
topic Ischemic Stroke
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8606438/
https://www.ncbi.nlm.nih.gov/pubmed/33514609
http://dx.doi.org/10.1136/neurintsurg-2020-016680
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