Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

Abstract

Background and purpose: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service.

Methods: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0-1, or a decrease from baseline of ≤8, at 24 h after stroke onset.

Results: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different.

Conclusion: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.

Keywords: Endovascular thrombectomy; Ischaemic stroke; Large vessel occlusion.

Fig. 1

Contraindications to intravenous thrombolysis (n = 29). Out of time (>4.5 h from onset), n = 6 (wake-up strokes/uncertain onset, n = 5); recent surgery (within 14 days), n = 5; recent myocardial infarction (MI) (within 30 days), n = 2; acute injury (during stroke ictus), n = 3; therapeutic anticoagulation, n = 5; previous intracranial haemorrhage, n = 2; NIHSS too high (>25), n = 2; subacute infracts (on initial imaging), n = 1; agitation (patient agitated/violent), n = 1; previous gastrointestinal (GI) bleeding, n = 1.