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Mechanical Thrombectomy Outcomes With or Without IV tPA
Study Questions:
How do outcomes differ for acute ischemic stroke patients with large vessel occlusion (LVO) who receive intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) before mechanical thrombectomy (MT) compared to those who do not receive IV tPA before MT?
Methods:
This was a post hoc analysis of the ASTER (Contact Aspiration Versus Stent Retriever for Successful Revascularization) randomized controlled trial, which enrolled stroke patients with an anterior circulation (carotid terminus, M1 or M2) LVO within 6 hours of symptom onset. Patients who received IV tPA before MT were compared to patients who received MT alone. The primary outcome for this analysis was favorable modified Rankin scale (mRS) score of ≤2 at 90 days. Secondary outcomes included intracerebral hemorrhage (ICH) rates and 90-day mortality.
Results:
A total of 381 patients were randomized in the original ASTER trial and all 381 were included in this analysis; 250 patients (65.6%) received both IV tPA and MT, and 131 patients (34.3%) received MT alone. There was no difference between the IV tPA + MT group and the MT alone group in favorable (≤2) mRS score at 90 days (adjusted risk ratio [aRR], 1.27; 95% confidence interval [CI], 0.95-1.72). However, 90-day mortality was lower in the IV tPA + MT group (14.8%) than in the MT alone group (27.8%) (aRR, 0.59; 95% CI, 0.39-0.88) after adjustment for potential confounders including baseline National Institutes of Health Stroke Scale score and onset to arterial puncture time. There was no significant difference in any ICH, parenchymal hematoma, or symptomatic ICH between the two groups. Among patients who were not on anticoagulation before stroke onset, 90-day favorable outcome was higher in the IV tPA + MT group than in the MT alone group (aRR, 1.38; 95% CI, 1.02-1.89).
Conclusions:
No difference in favorable 90-day outcome was found between the IV tPA + MT group and the MT alone group. However, 90-day mortality was lower in the IV tPA + MT group than in the MT alone group.
Perspective:
These data should be interpreted with caution given that patients who have contraindications to IV tPA tend to be sicker (e.g., recent surgery, bleeding diathesis) than patients without contraindications, which may bias the results against the MT alone group. However, practically speaking, these results support the current practice of providing IV tPA as quickly as possible to all eligible stroke patients, regardless of whether MT will ultimately be pursued.
Keywords: Anticoagulants, Brain Ischemia, Cerebral Hemorrhage, Coronary Occlusion, Hematoma, Outcome Assessment, Health Care, Secondary Prevention, Stents, Stroke, Thrombectomy, Thrombolytic Therapy, Tissue Plasminogen Activator, Vascular Diseases
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