Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion

Nitin Goyal; Georgios Tsivgoulis; Donald Frei; Aquilla Turk; Blaise Baxter; Michael T Froehler; J Mocco; Abhi Pandhi; Ramin Zand; Konark Malhotra; Daniel Hoit; Lucas Elijovich; David Loy; Raymond D Turner; Justin Mascitelli; Kiersten Espaillat; Aristeidis H Katsanos; Anne W Alexandrov; Andrei V Alexandrov; Adam S Arthur

doi:10.1212/WNL.0000000000005299

Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion

Neurology. 2018 Apr 10;90(15):e1274-e1282. doi: 10.1212/WNL.0000000000005299. Epub 2018 Mar 16.

Authors

Nitin Goyal¹, Georgios Tsivgoulis¹, Donald Frei¹, Aquilla Turk¹, Blaise Baxter¹, Michael T Froehler¹, J Mocco¹, Abhi Pandhi¹, Ramin Zand¹, Konark Malhotra¹, Daniel Hoit¹, Lucas Elijovich¹, David Loy¹, Raymond D Turner¹, Justin Mascitelli¹, Kiersten Espaillat¹, Aristeidis H Katsanos¹, Anne W Alexandrov¹, Andrei V Alexandrov¹, Adam S Arthur²

Affiliations

¹ From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis.
² From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis. aarthur@semmes-murphey.com.

PMID: 29549221
DOI: 10.1212/WNL.0000000000005299

Abstract

Objective: In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients.

Methods: Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0-2 at 3 months], favorable functional outcome [mRS of 0-1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed.

Results: A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02-2.99) and functional improvement (common OR 1.64; 95% CI 1.05-2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26-0.96).

Conclusions: This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial.

Classification of evidence: This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.

Publication types

Multicenter Study
Observational Study

MeSH terms

Brain Ischemia / therapy*
Combined Modality Therapy / adverse effects
Female
Humans
Male
Mechanical Thrombolysis* / adverse effects
Mechanical Thrombolysis* / methods
Middle Aged
Propensity Score
Prospective Studies
Retrospective Studies
Stroke / therapy*
Thrombolytic Therapy* / adverse effects
Thrombolytic Therapy* / methods
Treatment Outcome