Mechanical Thrombectomy Versus Intravenous Thrombolysis in Distal Medium Vessel Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Matched Study

Hamza Adel Salim^{1

2}, Vivek Yedavalli¹, Basel Musmar³, Nimer Adeeb³, Muhammed Amir Essibayi⁴, Kareem El Naamani⁵, Nils Henninger^{6

7}, Sri Hari Sundararajan⁸, Anna Luisa Kühn⁹, Jane Khalife¹⁰, Sherief Ghozy¹¹, Luca Scarcia¹², Benjamin Y Q Tan^{13

14}, Benjamin Pulli¹⁵, Jeremy J Heit¹⁵, Robert W Regenhardt², Nicole M Cancelliere¹⁶, Joshua D Bernstock¹⁷, Aymeric Rouchaud¹⁸, Jens Fiehler^{10

19}, Sunil Sheth²⁰, Ajit S Puri⁹, Christian Dyzmann²¹, Marco Colasurdo²², Xavier Barreau²³, Leonardo Renieri²⁴, João Pedro Filipe²⁵, Pablo Harker²⁶, Razvan Alexandru Radu²⁷, Thomas R Marotta¹⁶, Julian Spears¹⁶, Takahiro Ota²⁸, Ashkan Mowla²⁹, Pascal Jabbour⁵, Arundhati Biswas³⁰, Frédéric Clarençon³¹, James E Siegler¹⁰, Thanh N Nguyen³², Ricardo Varela³³, Amanda Baker⁴, David Altschul⁴, Nestor R Gonzalez³⁴, Markus A Möhlenbruch³⁵, Vincent Costalat²⁷, Benjamin Gory^{36

37}, Christian Paul Stracke³⁸, Mohammad Ali Aziz-Sultan¹⁷, Constantin Hecker³⁹, Hamza Shaikh¹⁰, David S Liebeskind⁴⁰, Alessandro Pedicelli⁴¹, Andrea M Alexandre⁴¹, Illario Tancredi⁴², Tobias D Faizy¹⁹, Erwah Kalsoum¹², Boris Lubicz⁴³, Aman B Patel², Vitor Mendes Pereira¹⁶, Adrien Guenego⁴³, Adam A Dmytriw^{2

16}; MAD MT Investigators¹

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
³ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, LA, USA.
⁴ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁵ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁶ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁷ Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
⁸ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
⁹ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁰ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹¹ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹² Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹³ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁴ Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁵ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁶ Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada.
¹⁷ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁸ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, Limoges, France.
¹⁹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁰ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
²³ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
²⁴ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁵ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁶ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁷ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁸ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
³⁰ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³¹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³² Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
³³ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁴ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁵ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁶ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁷ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
³⁸ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
³⁹ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴⁰ UCLA Stroke Center and Department of Neurology Department, University of California, Los Angeles, Los Angeles, CA, USA.
⁴¹ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Roma, Italy.
⁴² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴³ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 39266014
PMCID: PMC11471362
DOI: 10.5853/jos.2024.01389

Mechanical Thrombectomy Versus Intravenous Thrombolysis in Distal Medium Vessel Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Matched Study

Hamza Adel Salim et al. J Stroke. 2024 Sep.

. 2024 Sep;26(3):434-445.

doi: 10.5853/jos.2024.01389. Epub 2024 Sep 13.

Authors

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
³ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, LA, USA.
⁴ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁵ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁶ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁷ Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
⁸ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
⁹ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁰ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹¹ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹² Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹³ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁴ Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁵ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁶ Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada.
¹⁷ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁸ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, Limoges, France.
¹⁹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁰ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
²³ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
²⁴ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁵ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁶ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁷ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁸ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
³⁰ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³¹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³² Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
³³ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁴ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁵ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁶ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁷ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
³⁸ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
³⁹ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴⁰ UCLA Stroke Center and Department of Neurology Department, University of California, Los Angeles, Los Angeles, CA, USA.
⁴¹ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Roma, Italy.
⁴² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴³ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 39266014
PMCID: PMC11471362
DOI: 10.5853/jos.2024.01389

Abstract

Background and purpose: The management of acute ischemic stroke (AIS) due to distal medium vessel occlusion (DMVO) remains uncertain, particularly in comparing the effectiveness of intravenous thrombolysis (IVT) plus mechanical thrombectomy (MT) versus IVT alone. This study aimed to evaluate the safety and efficacy in DMVO patients treated with either MT-IVT or IVT alone.

Methods: This multinational study analyzed data from 37 centers across North America, Asia, and Europe. Patients with AIS due to DMVO were included, with data collected from September 2017 to July 2023. The primary outcome was functional independence, with secondary outcomes including mortality and safety measures such as types of intracerebral hemorrhage.

Results: The study involved 1,057 patients before matching, and 640 patients post-matching. Functional outcomes at 90 days showed no significant difference between groups in achieving good functional recovery (modified Rankin Scale 0-1 and 0-2), with adjusted odds ratios (OR) of 1.21 (95% confidence interval [CI] 0.81 to 1.79; P=0.35) and 1.00 (95% CI 0.66 to 1.51; P>0.99), respectively. Mortality rates at 90 days were similar between the two groups (OR 0.75, 95% CI 0.44 to 1.29; P=0.30). The incidence of symptomatic intracerebral hemorrhage was comparable, but any type of intracranial hemorrhage was significantly higher in the MT-IVT group (OR 0.43, 95% CI 0.29 to 0.63; P<0.001).

Conclusion: The results of this study indicate that while MT-IVT and IVT alone show similar functional and mortality outcomes in DMVO patients, MT-IVT presents a higher risk of hemorrhagic complications, thus MT-IVT may not routinely offer additional benefits over IVT alone for all DMVO stroke patients. Further prospective randomized trials are needed to identify patient subgroups most likely to benefit from MT-IVT treatment in DMVO.

Keywords: Distal medium vessel occlusions; Mechanical thrombectomy; Stroke.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest

Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. Dr. Henninger received support from CDMRP/DoD W81XWH-19-PRARP-RPA and NINDS NS131756, during the conduct of the study. Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work. Dr. Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr. Jabbour is a consultant for Medtronic, Microvention and Cerus. All remaining authors have declared no conflicts of interest.

Figures

**Figure 1.**
Patient selection and propensity score matching flowchart. mRS, modified Rankin Scale; MT, mechanical thrombectomy; IVT, intravenous thrombolysis; PSM, propensity score matching ratio. ^*Multipl selection of patients possible.

**Figure 2.**
Comparative outcomes of MT-IVT versus IVT alone. (A) The percentage distribution of 90-day mRS scores for patients treated with IVT alone compared to those who received MT in addition to IVT (MT-IVT). The mRS scores range from 0 (no symptoms) to 6 (death), with the number of patients achieving each score level represented by the length of the bars along the X-axis. (B) The proportion of patients experiencing various types of hemorrhagic complications post-treatment. mRS, modified Rankin Scale; IVT, intravenous thrombolysis; MT, mechanical thrombectomy; sICH, symptomatic intracerebral hemorrhage; ICH, intracerebral hemorrhage; SAH, subarachnoid hemorrhage; HI1, hemorrhagic infarction type 1; HI2, hemorrhagic infarction type 2; PH1, parenchymal hematoma type 1; PH2, parenchymal hematoma type 2. ^***P<0.001.

**Figure 3.**
Subgroup analysis by scenario “Drip and Ship” versus “Mothership.” mRS, modified Rankin Scale; MT, mechanical thrombectomy; IVT, intravenous thrombolysis; ICH, intracerebral hemorrhage; sICH, symptomatic intracerebral hemorrhage; OR, odds ratio; CI, confidence interval.

**Figure 4.**
Subgroup analysis by location medium versus distal. mRS, modified Rankin Scale; MT, mechanical thrombectomy; IVT, intravenous thrombolysis; ICH, intracerebral hemorrhage; sICH, symptomatic intracerebral hemorrhage; SAH, subarachnoid hemorrhage; OR, odds ratio; CI, confidence interval.

See this image and copyright information in PMC

References

1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. - PubMed
1. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–2306. - PubMed
1. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–2295. - PubMed
1. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–1030. - PubMed
1. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–1731. - PubMed

Grants and funding

R21 NS131756/NS/NINDS NIH HHS/United States

LinkOut - more resources

Full Text Sources
- M2PI
- PubMed Central

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Mechanical Thrombectomy Versus Intravenous Thrombolysis in Distal Medium Vessel Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Matched Study

Affiliations

Mechanical Thrombectomy Versus Intravenous Thrombolysis in Distal Medium Vessel Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Matched Study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Grants and funding

LinkOut - more resources

Full Text Sources