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Meta-Analysis
. 2023 Nov;15(e2):e232-e239.
doi: 10.1136/jnis-2022-019585. Epub 2022 Nov 17.

Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial

Adnan Mujanovic  1 , Omer Eker  2 , Gaultier Marnat  3 , Daniel Strbian  4 , Petra Ijäs  4 , Cécile Préterre  5 , Aude Triquenot  6 , Jean François Albucher  7 , Maxime Gauberti  8 , David Weisenburger-Lile  9 , Marielle Ernst  10 , Omid Nikoubashman  11 , Anastasios Mpotsaris  12 , Benjamin Gory  13 , Vi Tuan Hua  14 , Marc Ribo  15 , David S Liebeskind  16 , Tomas Dobrocky  1 , Thomas R Meinel  17 , Lukas Buetikofer  18 , Jan Gralla  1 , Urs Fischer #  17   19 , Johannes Kaesmacher #  20 ; SWIFT DIRECT investigators
Affiliations
Meta-Analysis

Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial

Adnan Mujanovic et al. J Neurointerv Surg. 2023 Nov.

Abstract

Background: A potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there are few data on the occurrence of pre-interventional reperfusion in patients randomized to IVT or no IVT before MT.

Methods: SWIFT DIRECT (Solitaire With the Intention For Thrombectomy Plus Intravenous t-PA vs DIRECT Solitaire Stent-retriever Thrombectomy in Acute Anterior Circulation Stroke) was a randomized controlled trial including acute ischemic stroke IVT eligible patients being directly admitted to a comprehensive stroke center, with allocation to IVT with MT versus MT alone. The primary endpoint of this analysis was the occurrence of pre-interventional reperfusion, defined as a pre-interventional expanded Thrombolysis in Cerebral Infarction score of ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses.

Results: Of 396 patients, pre-interventional reperfusion occurred in 20 (10.0%) patients randomized to IVT with MT, and in 7 (3.6%) patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (adjusted OR 2.91, 95% CI 1.23 to 6.87). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture time (p for interaction=0.33), although the effect tended to be stronger in patients with a Randomization-to-Groin-Puncture time >28 min (adjusted OR 4.65, 95% CI 1.16 to 18.68). There were no significant differences in rates of functional outcomes between patients with and without pre-interventional reperfusion.

Conclusion: Even for patients with proximal large vessel occlusions and direct access to MT, IVT resulted in an absolute increase of 6% in rates of pre-interventional reperfusion. The influence of time strata on the occurrence of pre-interventional reperfusion should be studied further in an individual patient data meta-analysis of comparable trials.

Trial registration number: clinicaltrials.gov NCT03192332.

Keywords: Stroke; Thrombectomy; Thrombolysis.

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Conflict of interest statement

Competing interests: GM reports consulting fees from Stryker Neurovascular, and paid lectures for Medtronic and Microvention Europe. ON reports funding from a Stryker research grant, and payment or honoraria for Phenox lecture and Stryker lecture. MR reports consulting fees from Medtronic, Stryker, Cerenovus, Philips, and Apta Targets; payment or honoraria from Ischemia View; participates on a data safety monitoring board or advisory board of Sensome; and has stock or stock options in Anaconda Biomed, CVAid, and Methinks. DSL reports consulting fees from Cerenovus, Genentech, Medtronic, Stryker, and Rapid Medical as imaging core laboratory. JG reports a Swiss National Funds grant for MRI in stroke. UF reports financial support for the present study from Medtronic; research grants from Medtronic BEYOND SWIFT registry, the Swiss National Science Foundation, and the Swiss Heart Foundation; consulting fees from Medtronic, Stryker, and CSL Behring (fees paid to institution); has membership of a data safety monitoring board for the IN EXTREMIS trial and the TITAN trial; was on the advisory board for Portola (Alexion; fees paid to institution); is an editor at the Journal of Neurointerventional Surgery; and is Vice President of the Swiss Neurological Society. JK reports financial support from Medtronic for the BEYOND SWIFT registry (fees paid to institution), and research grants from the Swiss National Science Foundation supporting the TECNO trial (fees paid to institution), Swiss Academy of Medical Sciences supporting MRI research (fees paid to institution), and Swiss Heart Foundation supporting cardiac MRI in the etiological work-up of stroke patients (fees paid to institution).

Figures

Figure 1
Figure 1
Odds ratio (OR) for pre-interventional reperfusion by allocation to thrombectomy alone versus alteplase plus thrombectomy. ORs are based on Firth logistic regressions adjusted for stratification factors and sex (see Methods). For subgroups, marginal effects from interaction models are presented. There was no significant interaction for Randomization-to-Groin-Puncture time (p=0.33) or presence of distal occlusions (p=0.47) on the effect of intravenous thrombolysis regarding the occurrence of pre-interventional reperfusion, although the effect tended to be stronger in patients with Randomization-to-Groin-Puncture time >28 min (adjusted OR 4.65, 95% CI 1.16 to 18.68).
Figure 2
Figure 2
Effects of pre-interventional reperfusion on secondary outcomes. Secondary outcomes are mean difference or odds ratio (95% CI), based on linear ordinal logistic or logistic regression models adjusted for stratification factors and sex (see methods). Adjusted analysis on the effects of pre-interventional reperfusion showed no significant shift on the modified Rankin Scale at 3 months (adjusted OR 0.98, 95% CI 0.49 to 1.93), final eTICI 3 reperfusion (adjusted OR 1.44, 95% CI 0.61 to 3.42), and NIHSS status at 24 hours (mean difference 0.19, 95% CI −2.84 to 3.23). cs-eTICI, cross sectional expanded Thrombolysis in Cerebral Infarction; NIHSS, National Institutes of Health Stroke Scale; TICI, Thrombolysis in Cerebral Infarction
See this image and copyright information in PMC

References

    1. Tsivgoulis G, Katsanos AH, Schellinger PD, et al. . Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions. Stroke 2018;49:232–5. 10.1161/STROKEAHA.117.019261 - DOI - PMC - PubMed
    1. Kaesmacher J, Giarrusso M, Zibold F, et al. . Rates and quality of preinterventional reperfusion in patients with direct access to endovascular treatment. Stroke 2018;49:1924–32. 10.1161/STROKEAHA.118.021579 - DOI - PubMed
    1. Katsanos AH, Malhotra K, Goyal N, et al. . Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions. Ann Neurol 2019;86:395–406. 10.1002/ana.25544 - DOI - PubMed
    1. Ohara T, Menon BK, Al-Ajlan FS, et al. . Thrombus migration and fragmentation after intravenous alteplase treatment: the INTERRSeCT study. Stroke 2021;52:203–12. 10.1161/STROKEAHA.120.029292 - DOI - PubMed
    1. Ospel JM, Singh N, Almekhlafi MA, et al. . Early recanalization with alteplase in stroke because of large vessel occlusion in the ESCAPE trial. Stroke 2021;52:304–7. 10.1161/STROKEAHA.120.031591 - DOI - PubMed

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