Intravenous Thrombolysis Facilitates Successful Recanalization with Stent-Retriever Mechanical Thrombectomy in Middle Cerebral Artery Occlusions

https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.01.007Get rights and content

Aim

Several factors influence the outcome after acute ischemic stroke secondary to proximal occlusions of cerebral vessels. Among others, noneligibility for intravenous thrombolysis (IVT) and incomplete revascularization have been identified as predictors of unfavorable outcome. The aim of this study was to investigate whether concomitant IVT influences the revascularization efficacy in mechanical thrombectomy (MT).

Methods

This study conducted a retrospective analysis of all consecutive patients presenting with an anterior circulation stroke due to large-artery occlusion with imaging evidence who were treated with MT between July 2012 and December 2013 at 2 high-volume stroke centers. Imaging data were regraded and re-evaluated according to the modified Treatment in Cerebral Ischemia scale and its respective vessel occlusion site definitions. Clinical end points included National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale; imaging and procedural measures were technical end points.

Results

We identified 93 patients who presented with an occlusion of the middle cerebral artery (MCA): of these patients, 66 (71%) received IVT. We did not find statistically significant differences in the baseline NIHSS score, time from symptom onset to groin puncture, and age when comparing the IVT group with the non-IVT group. The rate of successful recanalizations (modified Treatment in Cerebral Ischemia score ≥ 2b) was significantly higher in patients with MCA occlusion and concomitant IVT (P = .01). Stepwise logistic regression identified IVT and thrombus length as predictive factors for successful mechanical recanalization (P = .004, P = .002).

Conclusion

IVT and thrombus length are predictive factors for a successful recanalization in MT for acute ischemic stroke with underlying MCA occlusion.

Section snippets

Materials and Methods

We screened the prospectively kept neurointerventional databases of 2 German stroke centers for all ischemic stroke patients presenting within 6 hours from symptom onset who underwent MT for an imaging-proven large-artery occlusion in the anterior circulation between July 2012 and December 2013. The administration of IVT was independent from the indication for MT and was performed by the treating stroke neurologist on the basis of the national guidelines of the Deutsche Gesellschaft für

Overview

We identified 93 patients who fulfilled the inclusion criteria; the site of occlusion was MCA (proximal M1 occlusion, distal M1 occlusion, and M2) in all cases.

Baseline Characteristics

We compared the baseline characteristics age, sex, NIHSS score on admission, and time from symptom onset to groin puncture of all patients who received IVT to those who did not receive IVT before MT. There were no statistically significant differences in patient baseline characteristics overall and by site of occlusion between the groups

Discussion

MT for the treatment of large-artery occlusions in acute ischemic stroke has been used in clinical practice for several years. Its efficacy, clinical results and complications have been investigated in several studies including large case series, postmarket registries, and prospective randomized clinical trials.7, 8, 18, 19 Recently, several randomized trials that utilized mostly or exclusively stent–retriever-based MT showed a benefit for MT versus non-MT in the setting of guideline-based best

Conclusion

Concomitant IVT and thrombus length are predictive factors for a successful recanalization in MT for acute ischemic stroke with underlying MCA occlusion. The current practice of IVT in eligible patients before MT should not be abandoned unless proven otherwise by future studies, now that more evidence for the beneficial effect of MT in ischemic stroke is available.

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    D. Behme and C. Kabbasch contributed equally to the work.

    D. Behme, A. Kowoll, and W. Weber changed departments in 2014; the patients were treated in Recklinghausen (teaching hospital of the Ruhr University Bochum) and Cologne.

    Conflicts of interest: D. Behme and A. Kowoll received minor travel grants from Penumbra. T. Liebig was a consultant for Sequent, Stryker, and Acandis. W. Weber was a consultant for Sequent, Microvention, and Phenox, and received speaking honoraria and travel grants from Penumbra. A. Mpotsaris received modest speaker honoraria from Penumbra and was a consultant for Sequent and Neuravi.

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