Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York Presbyterian/Weill Cornell Medical College
SOURCE: Smith EE, Zerna C, Solomon N, et al. Outcomes after endovascular thrombectomy with or without alteplase in routine clinical practice. JAMA Neurol 2022;79:768-776.
With the widespread adoption of endovascular thrombectomy for the treatment of acute ischemic stroke caused by large vessel occlusion, a
debate has raged about the role of intravenous thrombolysis. Guidelines for the treatment of acute ischemic stroke continue to recommend intravenous thrombolysis with alteplase within 4.5 hours of stroke symptom onset. If large vessel occlusion is found on imaging, patients move forward with endovascular thrombectomy.
There always has been a concern that combining intravenous thrombolysis with endovascular thrombectomy will result in increased risk of serious intracerebral hemorrhage. Some interventionists have recommended avoiding the use of intravenous thrombolysis. None of the clinical trials published to date have given us a clear evidence-based answer regarding the relative risks and benefits of this approach.
The current study is an analysis of data from 2019 and 2020, collected from the Get With The Guidelines – Stroke nationwide registry of patients with acute ischemic stroke submitted by 555 hospitals in the United States. During that period of time, 15,832 patients were treated with endovascular thrombectomy. The median age was 72 years, 50.1% were women, and 66.7% received alteplase prior to thrombectomy and 33.4% did not. Patients treated with alteplase tended to arrive more quickly to the emergency department and were younger. They were less likely to have comorbidities such as atrial fibrillation, hypertension, and diabetes. Initial National Institutes of Health Stroke Scale scores were similar to those who were not treated with alteplase.
Compared to patients who did not receive intravenous thrombolysis, patients treated with alteplase were less likely to die (11.1% vs. 13.9%), were more likely to have no major disability based on a modified Rankin Scale score of 2 or less at time of discharge (28.5% vs. 20.7%), and were more likely to have better reperfusion following thrombectomy. However, alteplase treatment was associated with a higher risk of symptomatic intracerebral hemorrhage (6.5% vs. 5.3%). Overall, patients treated with intravenous thrombolysis prior to endovascular thrombectomy had better in-hospital survival and functional outcomes but a slightly higher rate of symptomatic intracerebral hemorrhage.
