Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions

Georgios Tsivgoulis, Aristeidis H. Katsanos, Peter D. Schellinger, Martin Köhrmann, Panayiotis Varelas, Georgios Magoufis, Maurizio Paciaroni, Valeria Caso, Anne Alexandrov, Edip Gurol, Andrei Alexandrov

Research output: Contribution to journalArticle

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Abstract

Background and Purpose-Although current guidelines advocate pretreatment with intravenous thrombolysis (IVT) in all eligible patients with acute ischemic stroke with large-vessel occlusion before mechanical thrombectomy, there are observational data questioning the efficacy of this approach. One of the main arguments in favor of IVT pretreatment is the potential for tissue-type plasminogen activator-induced successful reperfusion (SR) before the onset of endovascular procedure. Methods-We performed a systematic review and meta-analysis of randomized controlled clinical trials and observational cohorts providing rates of SR with IVT in patients with large-vessel occlusion before the initiation of mechanical thrombectomy. We also performed subgroup analyses according to study type (randomized controlled clinical trials versus observational) and according to the inclusion per protocol of patients with tandem (intracranial/extracranial) occlusions. Results-We identified 13 eligible studies (7 randomized controlled clinical trials and 6 observational cohorts), including 1561 patients with acute ischemic stroke (median National Institutes of Health Stroke Scale score, 17) with large-vessel occlusion. SR following IVT and before mechanical thrombectomy was documented in 11% (95% confidence interval, 7%-16%), with no difference among cohorts derived from randomized controlled clinical trials and observational studies. There was significant heterogeneity across included studies both in the overall analysis and among subgroups (I2>84%; P for Cochran Q, <0.001). Higher tissue-type plasminogen activator-induced SR rates were documented in studies reporting the exclusion of tandem occlusions (17%; 95% confidence interval, 11%-23%) compared with the rest (7%; 95% confidence interval, 4%-11%; P for subgroup differences, 0.003). Conclusions-Pretreatment with systemic thrombolysis in patients with large-vessel occlusion eligible for mechanical thrombectomy results in SR in 1 of 10 cases, negating the need for additional endovascular reperfusion. Tandem occlusions seem to be the least responsive to IVT pretreatment.

Original languageEnglish (US)
Pages (from-to)232-235
Number of pages4
JournalStroke
Volume49
Issue number1
DOIs
StatePublished - Jan 1 2018

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Mechanical Thrombolysis
Thrombectomy
Reperfusion
Randomized Controlled Trials
Stroke
Tissue Plasminogen Activator
Confidence Intervals
Endovascular Procedures
National Institutes of Health (U.S.)
Observational Studies
Meta-Analysis
Guidelines

All Science Journal Classification (ASJC) codes

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions. / Tsivgoulis, Georgios; Katsanos, Aristeidis H.; Schellinger, Peter D.; Köhrmann, Martin; Varelas, Panayiotis; Magoufis, Georgios; Paciaroni, Maurizio; Caso, Valeria; Alexandrov, Anne; Gurol, Edip; Alexandrov, Andrei.

In: Stroke, Vol. 49, No. 1, 01.01.2018, p. 232-235.

Research output: Contribution to journalArticle

Tsivgoulis, G, Katsanos, AH, Schellinger, PD, Köhrmann, M, Varelas, P, Magoufis, G, Paciaroni, M, Caso, V, Alexandrov, A, Gurol, E & Alexandrov, A 2018, 'Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions', Stroke, vol. 49, no. 1, pp. 232-235. https://doi.org/10.1161/STROKEAHA.117.019261
Tsivgoulis, Georgios ; Katsanos, Aristeidis H. ; Schellinger, Peter D. ; Köhrmann, Martin ; Varelas, Panayiotis ; Magoufis, Georgios ; Paciaroni, Maurizio ; Caso, Valeria ; Alexandrov, Anne ; Gurol, Edip ; Alexandrov, Andrei. / Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions. In: Stroke. 2018 ; Vol. 49, No. 1. pp. 232-235.
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abstract = "Background and Purpose-Although current guidelines advocate pretreatment with intravenous thrombolysis (IVT) in all eligible patients with acute ischemic stroke with large-vessel occlusion before mechanical thrombectomy, there are observational data questioning the efficacy of this approach. One of the main arguments in favor of IVT pretreatment is the potential for tissue-type plasminogen activator-induced successful reperfusion (SR) before the onset of endovascular procedure. Methods-We performed a systematic review and meta-analysis of randomized controlled clinical trials and observational cohorts providing rates of SR with IVT in patients with large-vessel occlusion before the initiation of mechanical thrombectomy. We also performed subgroup analyses according to study type (randomized controlled clinical trials versus observational) and according to the inclusion per protocol of patients with tandem (intracranial/extracranial) occlusions. Results-We identified 13 eligible studies (7 randomized controlled clinical trials and 6 observational cohorts), including 1561 patients with acute ischemic stroke (median National Institutes of Health Stroke Scale score, 17) with large-vessel occlusion. SR following IVT and before mechanical thrombectomy was documented in 11{\%} (95{\%} confidence interval, 7{\%}-16{\%}), with no difference among cohorts derived from randomized controlled clinical trials and observational studies. There was significant heterogeneity across included studies both in the overall analysis and among subgroups (I2>84{\%}; P for Cochran Q, <0.001). Higher tissue-type plasminogen activator-induced SR rates were documented in studies reporting the exclusion of tandem occlusions (17{\%}; 95{\%} confidence interval, 11{\%}-23{\%}) compared with the rest (7{\%}; 95{\%} confidence interval, 4{\%}-11{\%}; P for subgroup differences, 0.003). Conclusions-Pretreatment with systemic thrombolysis in patients with large-vessel occlusion eligible for mechanical thrombectomy results in SR in 1 of 10 cases, negating the need for additional endovascular reperfusion. Tandem occlusions seem to be the least responsive to IVT pretreatment.",
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AU - Katsanos, Aristeidis H.

AU - Schellinger, Peter D.

AU - Köhrmann, Martin

AU - Varelas, Panayiotis

AU - Magoufis, Georgios

AU - Paciaroni, Maurizio

AU - Caso, Valeria

AU - Alexandrov, Anne

AU - Gurol, Edip

AU - Alexandrov, Andrei

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