Fast track — ArticlesComparison of intravenous alteplase with a combined intravenous–endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study
Introduction
Intravenous (IV) alteplase is recommended for acute ischaemic stroke within 3 h of symptom onset.1, 2 However, the efficacy of IV alteplase is limited by crucial parameters, such as recanalisation and the site of the arterial occlusion.3, 4, 5, 6 Recanalisation and distal occlusion are significantly associated with good functional outcome after acute ischaemic stroke, whereas patients with proximal occlusions have poor clinical outcome.7, 8 Recanalisation rates of 8·7% for occlusions of the internal carotid artery (ICA) and 35·3% for occlusions of the M1 segment of the middle cerebral artery (MCA) have been reported in patients treated with IV alteplase.9
Intra-arterial (IA) thrombolysis has proven efficacy in patients with occlusions of the MCA; recanalisation rates of 66% have been reported.10 IA thrombolysis has the advantages of arterial recanalisation monitoring and the potential for additional mechanical clot manipulation, but is limited by the “door-to-needle” time, which is more important than it is with IV thrombolysis because of the delay due to catheterisation time. The drawback of the delay in time to treatment associated with IA procedures might be resolved by the combination of IV and IA routes, which will have the speed of action of the IV route and the high recanalisation rate of the IA approach. The IV–IA approach is currently under investigation,11 but few data are available with regard to its feasibility, safety, and efficacy.
In the RECANALISE (REcanalisation using Combined intravenous Alteplase and Neurointerventional ALgorithm for acute Ischemic StrokE) study, our aim was to assess the combined IV–endovascular (IA with or without additional mechanical procedures) approach in patients with acute ischaemic stroke and documented arterial occlusion within 3 h in a single-centre observational study. During phase 1 (February, 2002, to March, 2007), patients with confirmed arterial occlusion within 3 h were given alteplase; during phase 2 (April, 2007, to October, 2008), patients were treated with the IV–endovascular approach. The study periods coincided with the introduction of systematic IV–IA thrombolysis at our centre.
Section snippets
Patients
Patients were identified from a prospective clinical registry of patients with acute ischaemic stroke who were treated between February, 2002, and October, 2008, at Bichat University Hospital, Paris, France. Before April, 2007, all patients were treated with IV alteplase in accordance with the National Institute of Neurological Disorders and Stroke (NINDS) guidelines12 with the following additional exceptions: signs of early infarct in more than a third of the MCA territory seen on CT scan or a
Results
Before April, 2007, 107 patients with complete occlusion (57% [61] confirmed by angiographic examination and 43% [46] by transcranial Doppler) were treated with IV alteplase; these patients were the control group. After April, 2007, 64 patients with acute ischaemic stroke who presented within 3 h of symptom onset with a confirmed arterial occlusion were eligible for the combined IV–endovascular approach; 11 patients were not treated with the combined IV–endovascular approach because no
Discussion
Compared with IV alteplase, the combined IV–endovascular approach achieved higher rates of recanalisation in patients with acute ischaemic stroke with confirmed arterial occlusion. Recanalisation rates were higher after the IV–endovascular approach, independently of the site of the occlusion and were associated with early neurological improvement and 90-day favourable outcome. Rates of recanalisation were 87% in the IV–endovascular group and 52% in the IV group (p<0·0001); the effect on
References (21)
- et al.
Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European–Australasian Acute Stroke Study Investigators
Lancet
(1998) - et al.
Thrombolysis with alteplase 3–4·5 h after acute ischaemic stroke (SITS-ISTR): an observational study
Lancet
(2008) - et al.
Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edn)
Chest
(2008) Guidelines for management of ischaemic stroke and transient ischaemic attack 2008
Cerebrovasc Dis
(2008)- et al.
Early dramatic recovery during intravenous tissue plasminogen activator infusion: clinical pattern and outcome in acute middle cerebral artery stroke
Stroke
(2002) - et al.
Timing of recanalization after tissue plasminogen activator therapy determined by transcranial Doppler correlates with clinical recovery from ischemic stroke
Stroke
(2000) - et al.
High rate of complete recanalization and dramatic clinical recovery during tPA infusion when continuously monitored with 2 MHz transcranial Doppler monitoring
Stroke
(2000) - et al.
Predictors of good outcome after intravenous tPA for acute ischemic stroke
Neurology
(2001) - et al.
Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator
Stroke
(2004) - et al.
Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke
Stroke
(2007)
Cited by (253)
Intravenous Tenectaplase for Treatment of Cerebral Emboli Occurring during Catheter-Based Angiography
2023, Journal of Vascular and Interventional RadiologyComparison of Anesthetic Agents Dexmedetomidine and Midazolam During Mechanical Thrombectomy
2021, Journal of Stroke and Cerebrovascular DiseasesIV tPA given in the golden hour for emergent large vessel occlusion stroke improves recanalization rates and clinical outcomes
2021, Journal of the Neurological SciencesPerioperative Management of Acute Central Nervous System Injury
2021, Perioperative Medicine: Managing for Outcome, Second EditionClinical outcomes of moderate to severe acute ischemic stroke in a telemedicine network
2019, Journal of Clinical Neuroscience