Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2023 Feb;8(1):17-25.
doi: 10.1136/svn-2022-001677. Epub 2022 Aug 4.

Intra-arterial thrombolytics during endovascular thrombectomy for acute ischaemic stroke in the MR CLEAN Registry

Sabine L Collette  1 , Reinoud P H Bokkers  2 , Aryan Mazuri  2 , Geert J Lycklama À Nijeholt  3 , Robert J van Oostenbrugge  4 , Natalie E LeCouffe  5 , Faysal Benali  6 , Charles B L M Majoie  7 , Jan Cees de Groot  2 , Gert Jan R Luijckx  8 , Maarten Uyttenboogaart  2   8 ; MR CLEAN Registry investigators
Affiliations
Randomized Controlled Trial

Intra-arterial thrombolytics during endovascular thrombectomy for acute ischaemic stroke in the MR CLEAN Registry

Sabine L Collette et al. Stroke Vasc Neurol. 2023 Feb.

Abstract

Introduction: The efficacy and safety of local intra-arterial (IA) thrombolytics during endovascular thrombectomy (EVT) for large-vessel occlusions is uncertain. We analysed how often IA thrombolytics were administered in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry, whether it was associated with improved functional outcome and assessed technical and safety outcomes compared with EVT without IA thrombolytics.

Methods: In this observational study, we included patients undergoing EVT for an acute ischaemic stroke in the anterior circulation from the MR CLEAN Registry (March 2014-November 2017). The primary endpoint was favourable functional outcome, defined as an modified Rankin Scale score ≤2 at 90 days. Secondary endpoints were reperfusion status, early neurological recovery and symptomatic intracranial haemorrhage (sICH). Subgroup analyses for IA thrombolytics as primary versus adjuvant revascularisation attempt were performed.

Results: Of the 2263 included patients, 95 (4.2%) received IA thrombolytics during EVT. The IA thrombolytics administered were urokinase (median dose, 250 000 IU (IQR, 1 93 750-2 50 000)) or alteplase (median dose, 20 mg (IQR, 12-20)). No association was found between IA thrombolytics and favourable functional outcome (adjusted OR (aOR), 1.16; 95% CI 0.71 to 1.90). Successful reperfusion was less often observed in those patients treated with IA thrombolytics (aOR, 0.57; 95% CI 0.36 to 0.90). The odds of sICH (aOR, 0.82; 95% CI 0.32 to 2.10) and early neurological recovery were comparable between patients treated with and without IA thrombolytics. For primary and adjuvant revascularisation attempts, IA thrombolytics were more often administered for proximal than for distal occlusions. Functional outcomes were comparable for patients receiving IA thrombolytics as a primary versus adjuvant revascularisation attempt.

Conclusion: Local IA thrombolytics were rarely used in the MR CLEAN Registry. In the relatively small study sample, no statistical difference was observed between groups in the rate of favourable functional outcome or sICH. Patients whom required and underwent IA thrombolytics were patients less likely to achieve successful reperfusion, probably due to selection bias.

Keywords: Stroke; Thrombectomy; Thrombolytic Therapy.

PubMed Disclaimer

Conflict of interest statement

Competing interests: Amsterdam University Medical Centre received funds from Stryker® for consultations by Prof. Dr. Majoie, Prof. Dr. Roos, and Drs. Berkhemer. Maastricht University Medical Centre received funds from Stryker® and Codman® for consultations by Prof. Dr. Van Zwam. Prof. Dr. Majoie: Related: Grants TWIN Foundation; Unrelated: Grants from CVON/Dutch Heart Foundation, Stryker, European Commission, TWIN Foundation, Health Evaluation Netherlands (all paid to institution); shareholder of Nico-lab, a company that focuses on the use of artificial intelligence for medical image analysis (modest). The other authors report no conflicts.

Figures

Figure 1
Figure 1
Flowchart of included patients. IA, intra-arterial; MR CLEAN, Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; M3, middle cerebral artery, third segment; M4, middle cerebral artery, fourth segment; mRS, modified Rankin Scale; n, number. aEndovascularly was defined as arterial puncture in the angiography suite.
Figure 2
Figure 2
Distribution on the modified Rankin Scale. IA, intra-arterial; mRS, modified Rankin Scale.
See this image and copyright information in PMC

References

    1. del Zoppo GJ, Higashida RT, Furlan AJ, et al. . Proact: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. Stroke 1998;29:4–11. 10.1161/01.STR.29.1.4 - DOI - PubMed
    1. Furlan A, Higashida R, Wechsler L, et al. . Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 1999;282:2003–11. 10.1001/jama.282.21.2003 - DOI - PubMed
    1. Ogawa A, Mori E, Minematsu K, et al. . Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic intervention trial (melt) Japan. Stroke 2007;38:2633–9. 10.1161/STROKEAHA.107.488551 - DOI - PubMed
    1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group . Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–8. 10.1056/NEJM199512143332401 - DOI - PubMed
    1. Hacke W, Kaste M, Fieschi C, et al. . Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European cooperative acute stroke study (ECASS). JAMA 1995;274:1017–25. - PubMed

Publication types

MeSH terms

Substances