TY - JOUR
T1 - Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke
AU - Chalos, Vicky
AU - LeCouffe, Natalie E.
AU - Uyttenboogaart, Maarten
AU - Lingsma, Hester F.
AU - Mulder, Maxim J. H. L.
AU - Venema, Esmee
AU - Treurniet, Kilian M.
AU - Eshghi, Omid
AU - van der Worp, H. Bart
AU - van der Lugt, Aad
AU - Roos, Yvo B. W. E. M.
AU - Majoie, Charles B. L. M.
AU - Dippel, Diederik W. J.
AU - Roozenbeek, Bob
AU - Coutinho, Jonathan M.
AU - van Oostenbrugge, Robert J.
AU - van Zwam, Wim H.
AU - Boiten, Jelis
AU - Vos, Jan Albert
AU - Jansen, Ivo G. H.
AU - Goldhoorn, Robert-Jan B.
AU - Schonewille, Wouter J.
AU - Wermer, Marieke J. H.
AU - van Walderveen, Marianne A. A.
AU - Staals, Julie
AU - Hofmeijer, Jeannette
AU - Martens, Jasper M.
AU - Nijeholt, Geert J. Lycklama A.
AU - Emmer, Bart J.
AU - de Bruijn, Sebastiaan F.
AU - van Dijk, Lukas C.
AU - Lo, Rob H.
AU - van Dijk, Ewoud J.
AU - Boogaarts, Hieronymus D.
AU - de Kort, Paul L. M.
AU - Peluso, Jo J. P.
AU - van den Berg, Jan S. P.
AU - van Hasselt, Boudewijn A. A. M.
AU - Aerden, Leo A. M.
AU - Dallinga, Rene J.
AU - Schreuder, Tobien H. C. M. L.
AU - Heijboer, Roel J. J.
AU - Keizer, Koos
AU - Yo, Lonneke S. F.
AU - den Hertog, Heleen M.
AU - Sturm, Emiel J. C.
AU - Sprengers, Marieke E. S.
AU - Jenniskens, Sjoerd F. M.
AU - Hinsenveld, Wouter
AU - Groot, P. F. C.
AU - MR CLEAN Registry Investigators
N1 - Funding Information:
CVON/Dutch Heart Foundation, Dutch Brain Foundation, Stryker, Medtronic, and Penumbra for the conduct of studies for acute ischemic stroke and acute intracerebral hemorrhage. Amsterdam UMC, University of Amsterdam received compensation from Strykerâ for consultations by Dr Majoie and Dr Roos. Dr Majoie also reports that Amsterdam UMC, University of Amsterdam received unrestricted grants from CVON/Dutch Heart Foundation, European Commission, TWIN Foundation, and Stryker. Dr Majoie and Dr Roos are shareholders of Nico-lab. UMC Utrecht received grants from the Dutch Heart Foundation and compensation from Boehringer Ingelheim for consultations by Dr Van der Worp. The remaining authors have no disclosures to report.
Funding Information:
The authors received no funding for this study. The MR CLEAN Registry was partly funded by Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN) Foundation, Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC, University of Amsterdam.
Funding Information:
Dr LeCouffe, Dr Treurniet, and Dr Coutinho are research coordinators for the MR CLEAN-NO IV trial (ISRCTN80619088). Dr Roos and Dr Majoie are principal investigators of the MR CLEAN-NO IV trial. Dr Chalos, Dr Dippel, Dr van der Lugt, Dr Uyttenboogaart, Dr Lingsma, and Dr Roozenbeek are members of the CONTRAST (Collaboration for New Treatments of Acute Stroke) Consortium. Erasmus MC University Medical Center Rotterdam received compensation from Strykerâ for consultations by Dr Dippel, Dr van der Lugt, and from Bracco Imagingâ for consultations by Dr Dippel. Dr Dippel also reports research grants from Dutch Heart Foundation, Dutch Brain Foundation, and unrestricted grants from AngioCare BV, Medtronic/Covi-dien/EV3â, MEDAC Gmbh/LAMEPRO, Penumbra Inc, Strykerâ, and Top Medical/Concentric (all paid to the institution Erasmus MC University Medical Center Rotterdam). Dr van der Lugt also reports that Erasmus MC University Medical Center Rotterdam received unrestricted grants from
Publisher Copyright:
© 2019 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
PY - 2019/6/4
Y1 - 2019/6/4
N2 - Background-It is unclear whether intravenous thrombolysis (IVT) with alteplase before endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice.Methods and Results-Using multivariable regression, we evaluated the association of IVT+EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT+EVT, and 324 (22%) with EVT alone. Patients treated with IVT+EVT had atrial fibrillation less often (16% versus 44%) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT+EVT group (median 62 versus 68 minutes). Nontransferred IVT+EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT+EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI: 1.10-1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI: 0.40-0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups.Conclusions-In this observational study, patients treated with IVT+EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT.
AB - Background-It is unclear whether intravenous thrombolysis (IVT) with alteplase before endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice.Methods and Results-Using multivariable regression, we evaluated the association of IVT+EVT with 90-day functional outcome (modified Rankin Scale), mortality, reperfusion, first-pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT+EVT, and 324 (22%) with EVT alone. Patients treated with IVT+EVT had atrial fibrillation less often (16% versus 44%) and had better pre-stroke modified Rankin Scale scores (pre-stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT+EVT group (median 62 versus 68 minutes). Nontransferred IVT+EVT patients had longer door-to-groin-puncture times (median 105 versus 94 minutes). IVT+EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI: 1.10-1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI: 0.40-0.82). Successful reperfusion, first-pass effect, and symptomatic intracranial hemorrhage did not differ between groups.Conclusions-In this observational study, patients treated with IVT+EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT.
KW - endovascular treatment
KW - large vessel occlusion
KW - stroke
KW - thrombectomy
KW - thrombolysis
KW - DIRECT MECHANICAL THROMBECTOMY
KW - ANTERIOR CIRCULATION STROKE
KW - OUTCOMES
KW - RECANALIZATION
KW - THERAPY
KW - REPERFUSION
U2 - 10.1161/JAHA.118.011592
DO - 10.1161/JAHA.118.011592
M3 - Article
C2 - 31140355
SN - 2047-9980
VL - 8
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 11
M1 - 011592
ER -