Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy.

Campbell, Bruce C V; Kappelhof, Manon; Fischer, Urs (2022). Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy. Stroke, 53(6), pp. 2085-2092. American Heart Association 10.1161/STROKEAHA.122.036929

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Intravenous thrombolytics and endovascular thrombectomy for ischemic stroke have evolved in parallel. However, the best approach to combine these reperfusion therapies in patients eligible for both strategies remains uncertain. Initial randomized trials of endovascular thrombectomy included administration of intravenous thrombolytics to all eligible patients. However, whether that is of net benefit has been questioned and parallels drawn with treatment of ST-segment-elevation myocardial infarction, where intravenous thrombolytics are only given if first medical contact to percutaneous intervention is expected to be >90 minutes. Six randomized trials of a direct thrombectomy approach versus intravenous thrombolytics followed by endovascular thrombectomy have now reported their results. With exception of a minority of patients in one trial, the trials all used alteplase rather than potentially more effective tenecteplase. This review examines the current state of evidence and implications for clinical practice. Importantly, these trials only apply to patients who present to a hospital with immediate access to endovascular thrombectomy and are not relevant to patients who receive thrombolytic and are then transferred to an endovascular-capable hospital. Although 2 of the 6 randomized trials met their prespecified noninferiority margin, these margins were large compared with the absolute benefit of alteplase. Overall, functional outcome was similar, with slight trends favoring bridging thrombolytics and a significant increase in final reperfusion. Symptomatic hemorrhage was increased by ≈1.8% in the bridging group but death was nonsignificantly lower. The workflow in direct thrombectomy trials involved delaying thrombolytic administration until eligibility for thrombectomy and the trials was established and randomization completed. This reduced the time available for thrombolytics to occur prethrombectomy compared with standard practice. We conclude that, pending individual-patient data meta-analyses, intravenous thrombolytics retain an important role alongside endovascular thrombectomy. Further efforts to accelerate and enhance reperfusion with thrombolytics and perform individual patient-level pooled subgroup analyses are warranted.

Item Type:

Journal Article (Review Article)

Division/Institute:

04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology

UniBE Contributor:

Fischer, Urs Martin

Subjects:

600 Technology > 610 Medicine & health

ISSN:

1524-4628

Publisher:

American Heart Association

Language:

English

Submitter:

Pubmed Import

Date Deposited:

01 Apr 2022 09:43

Last Modified:

02 Mar 2023 23:36

Publisher DOI:

10.1161/STROKEAHA.122.036929

PubMed ID:

35354294

Uncontrolled Keywords:

computed tomography angiography ischemic stroke perfusion reperfusion thrombectomy thrombolytic therapy

BORIS DOI:

10.48350/168860

URI:

https://boris.unibe.ch/id/eprint/168860

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