Key result
Pre-thrombectomy IV tPA linked to ~0.8-point lower 90-day mRS score vs. thrombectomy alone.
Why the study?
The benefit of intravenous tPA prior to mechanical thrombectomy for large vessel occlusion may vary based on administration timing and site, with concerns about clot migration and hemorrhagic transformation.
Cohort (n=170)
No
Mean Difference: -0.775 (95% CI -1.531–-0.019)
Absolute Event Rate: 3.4% vs 4.4%
p-value: p=0.045
Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital. Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds ( n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes. Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h. Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.
No takes yet. Share an insight, caveat, or question.
Chang et al. (2020) conducted a cohort in Acute ischemic stroke with large vessel occlusion (n=170). Intravenous tissue plasminogen activator (IV tPA) prior to mechanical thrombectomy vs. Mechanical thrombectomy alone was evaluated on Mean modified Rankin Scale (mRS) score at 90 days (MD -0.775, 95% CI -1.531 to -0.019, p=0.045). Intravenous tissue plasminogen activator prior to mechanical thrombectomy independently improved 90-day functional outcomes (mean mRS score difference of -0.775) compared to mechanical thrombectomy alone.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: