Endovascular Thrombectomy Versus Bridging Thrombolysis: Real-World Efficacy and Safety Analysis Based on a Nationwide Registry Study

Chang Geng, Sheng-De Li, Ding-Ding Zhang, Lin Ma, Guo-Wei Liu, Li-Qun Jiao, Jian-Min Liu, Wen-Huo Chen, Wu-Sheng Zhu, Chang-Ming Wen, Bin Peng, Chang Geng, Sheng-De Li, Ding-Ding Zhang, Lin Ma, Guo-Wei Liu, Li-Qun Jiao, Jian-Min Liu, Wen-Huo Chen, Wu-Sheng Zhu, Chang-Ming Wen, Bin Peng

Abstract

Background It was uncertain if direct endovascular thrombectomy (ET) was superior to bridging thrombolysis (BT) for patients with acute ischemic stroke caused by large-vessel occlusions. We aimed to examine real-world clinical outcomes of ET using nationwide registry data in China and to compare the efficacy and safety between BT and direct ET. Methods and Results Patients treated with ET from a nationwide registry study in China were included. Rapid neurological improvement, intracranial hemorrhage, and in-hospital mortality were compared between the 2 groups using multivariate logistic models and propensity-score matching analyses. A total of 7674 patients from 592 stroke centers were included. The median onset-to-puncture time, onset-to-door time, and door to puncture time were 290, 170, and 99 minutes, respectively. A total of 2069 (27.0%) patients received BT treatment. Patients in the BT group had a significantly shorter onset-to-puncture time (235 versus 323 minutes; P<0.001) and onset-to-door time (90 versus 222 minutes; P<0.001) compared with the direct ET group. The prior use of intravenous thrombolysis was associated with a higher rate of rapid neurological improvement (adjusted odds ratio [OR], 0.83; 95% CI, 0.71-0.96) and higher risk of intracranial hemorrhage (adjusted OR, 1.46; 95% CI, 1.18-1.80) in multivariate analyses and propensity-score matching analyses. Conclusions This study reflects the current application of ET in China. More patients received direct ET than BT. Our results suggested that favorable short-term outcomes could be achieved with BT compared with direct ET. Higher risk of intracranial hemorrhage was observed in the BT group.

Trial registration: ClinicalTrials.gov NCT03469206.

Keywords: endovascular thrombectomy; ischemic stroke; outcome; thrombolysis.

Conflict of interest statement

None.

Figures

Figure 1. Inclusion criteria of the final…
Figure 1. Inclusion criteria of the final data set.
DNT indicates door‐to‐needle time; DPT, door‐to‐puncture time; LOH, length of hospitalization; ONT, onset‐to‐needle time; OPT, onset‐to‐puncture time; and rtPA, recombinant tissue‐type plasminogen activator.
Figure 2. Distribution of change of National…
Figure 2. Distribution of change of National Institutes of Health Stroke Scale (NIHSS) scores at 0 h, 24 h, and 7 days in patients receiving bridging thrombolysis (BT) and endovascular thrombectomy (ET), before (A) and after (B) propensity‐score matching.
Change of NIHSS scores was divided into 4 groups: scores of ≥8, 1–7, 0, and

References

    1. Dhamoon MS, Moon YP, Paik MC, Sacco RL, Elkind MS. Trajectory of functional decline before and after ischemic stroke: the northern Manhattan study. Stroke. 2012;43:2180–2184. DOI: 10.1161/STROKEAHA.112.658922.
    1. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, et al. Heart disease and stroke statistics‐2017 update: a report from the American Heart Association. Circulation. 2017;135:e146–e603.
    1. Wang W, Jiang B, Sun H, Ru X, Sun D, Wang L, Wang L, Jiang Y, Li Y, Wang Y, et al. Prevalence, incidence, and mortality of stroke in China. Circulation. 2017;135:759–771. DOI: 10.1161/CIRCULATIONAHA.116.025250.
    1. Wu S, Wu B, Liu M, Chen Z, Wang W, Anderson CS, Sandercock P, Wang Y, Huang Y, Cui L, et al. Stroke in China: advances and challenges in epidemiology, prevention, and management. Lancet Neurol. 2019;18:394–405.
    1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. DOI: 10.1056/NEJMoa1411587.
    1. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, et al. Endovascular therapy for ischemic stroke with perfusion‐imaging selection. N Engl J Med. 2015;372:1009–1018. DOI: 10.1056/NEJMoa1414792.
    1. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–1030. DOI: 10.1056/NEJMoa1414905.
    1. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–2306. DOI: 10.1056/NEJMoa1503780.
    1. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, et al. Stent‐retriever thrombectomy after intravenous t‐pa vs. T‐pa alone in stroke. N Engl J Med. 2015;372:2285–2295. DOI: 10.1056/NEJMoa1415061.
    1. Mistry EA, Mistry AM, Nakawah MO, Chitale RV, James RF, Volpi JJ, Fusco MR. Mechanical thrombectomy outcomes with and without intravenous thrombolysis in stroke patients: a meta‐analysis. Stroke. 2017;48:2450–2456. DOI: 10.1161/STROKEAHA.117.017320.
    1. Fiehler J, Cognard C, Gallitelli M, Jansen O, Kobayashi A, Mattle HP, Muir KW, Mazighi M, Schaller K, Schellinger PD. European recommendations on organisation of interventional care in acute stroke (EROICAS). Eur Stroke J. 2016;1:155–170. DOI: 10.1177/2396987316659033.
    1. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:3020–3035. DOI: 10.1161/STR.0000000000000074.
    1. Peng B, Wu B. Chinese guidelines for diagnosis and treatment for acute ischemic stroke 2018 (in Chinese). Chin J Neurol. 2018;51:666–682.
    1. Gamba M, Gilberti N, Premi E, Costa A, Frigerio M, Mardighian D, Vergani V, Spezi R, Delrio I, Morotti A, et al. Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results. BMC Neurol. 2019;19:103. DOI: 10.1186/s12883-019-1341-3.
    1. Fan L, Zang L, Liu X, Wang J, Qiu J, Wang Y. Outcomes of mechanical thrombectomy with pre‐intravenous thrombolysis: a systematic review and meta‐analysis. J Neurol. 2020. DOI: 10.1007/s00415-020-09778-4.
    1. Katsanos AH, Malhotra K, Goyal N, Arthur A, Schellinger PD, Kohrmann M, Krogias C, Turc G, Magoufis G, Leys D, et al. Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions. Ann Neurol. 2019;86:395–406. DOI: 10.1002/ana.25544.
    1. Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Clark W, Davalos A, Bonafe A, Jahan R, Fischer U, Gralla J, et al. Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the swift and star studies. JAMA Neurol. 2017;74:268–274. DOI: 10.1001/jamaneurol.2016.5374.
    1. Broeg‐Morvay A, Mordasini P, Bernasconi C, Buhlmann M, Pult F, Arnold M, Schroth G, Jung S, Mattle HP, Gralla J, et al. Direct mechanical intervention versus combined intravenous and mechanical intervention in large artery anterior circulation stroke: a matched‐pairs analysis. Stroke. 2016;47:1037–1044. DOI: 10.1161/STROKEAHA.115.011134.
    1. Bellwald S, Weber R, Dobrocky T, Nordmeyer H, Jung S, Hadisurya J, Mordasini P, Mono ML, Stracke CP, Sarikaya H, et al. Direct mechanical intervention versus bridging therapy in stroke patients eligible for intravenous thrombolysis: a pooled analysis of 2 registries. Stroke. 2017;48:3282–3288. DOI: 10.1161/STROKEAHA.117.018459.
    1. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, Peng Y, Han H, Wang J, Wang S, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382:1981–1993. DOI: 10.1056/NEJMoa2001123.
    1. Desilles JP, Loyau S, Syvannarath V, Gonzalez‐Valcarcel J, Cantier M, Louedec L, Lapergue B, Amarenco P, Ajzenberg N, Jandrot‐Perrus M, et al. Alteplase reduces downstream microvascular thrombosis and improves the benefit of large artery recanalization in stroke. Stroke. 2015;46:3241–3248. DOI: 10.1161/STROKEAHA.115.010721.
    1. Menon BK, Almekhlafi MA, Pereira VM, Gralla J, Bonafe A, Davalos A, Chapot R, Goyal M. Optimal workflow and process‐based performance measures for endovascular therapy in acute ischemic stroke: analysis of the solitaire FR thrombectomy for acute revascularization study. Stroke. 2014;45:2024–2029. DOI: 10.1161/STROKEAHA.114.005050.
    1. Leker RR, Pikis S, Gomori JM, Cohen JE. Is bridging necessary? A pilot study of bridging versus primary stentriever‐based endovascular reperfusion in large anterior circulation strokes. J Stroke Cerebrovasc Dis. 2015;24:1163–1167. DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.008.
    1. Shen Y, Chao BH, Cao L, Tu WJ, Wang LD. Stroke center care and outcome: results from the csppc stroke program. Transl Stroke Res. 2019;11:377–386. DOI: 10.1007/s12975-019-00727-6.
    1. Chao BH, Yan F, Hua Y, Liu JM, Yang Y, Ji XM, Peng B, Zhao GG, Wang YJ, Kang DZ, et al. Stroke prevention and control system in China: CSPPC‐stroke program. Int J Stroke. 2020;1747493020913557. DOI: 10.1177/1747493020913557.
    1. Wang G, Fang B, Yu X, Li Z. Interpretation of 2018 guidelines for the early management of patients with acute ischemic stroke. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2018;30:289–295.
    1. Brown DL, Johnston KC, Wagner DP, Haley EC Jr. Predicting major neurological improvement with intravenous recombinant tissue plasminogen activator treatment of stroke. Stroke. 2004;35:147–150. DOI: 10.1161/01.STR.0000105396.93273.72.
    1. Heit JJ, Mlynash M, Kemp SM, Lansberg MG, Christensen S, Marks MP, Ortega‐Gutierrez S, Albers GW. Rapid neurologic improvement predicts favorable outcome 90 days after thrombectomy in the defuse 3 study. Stroke. 2019;50:1172–1177. DOI: 10.1161/STROKEAHA.119.024928.
    1. Saposnik G, Di Legge S, Webster F, Hachinski V. Predictors of major neurologic improvement after thrombolysis in acute stroke. Neurology. 2005;65:1169–1174. DOI: 10.1212/01.wnl.0000180687.75907.4b.
    1. Austin PC. Propensity‐score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement. J Thorac Cardiovasc Surg. 2007;134:1128–1135. DOI: 10.1016/j.jtcvs.2007.07.021.
    1. Wollenweber FA, Tiedt S, Alegiani A, Alber B, Bangard C, Berrouschot J, Bode FJ, Boeckh‐Behrens T, Bohner G, Bormann A, et al. Functional outcome following stroke thrombectomy in clinical practice. Stroke. 2019;50:2500–2506. DOI: 10.1161/STROKEAHA.119.026005.
    1. Volny O, Krajina A, Belaskova S, Bar M, Cimflova P, Herzig R, Sanak D, Tomek A, Köcher M, Rocek M, et al. Mechanical thrombectomy performs similarly in real world practice: a 2016 nationwide study from the Czech Republic. J NeuroIntervent Surg. 2018;10:741–745. DOI: 10.1136/neurintsurg-2017-013534.
    1. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta‐analysis. JAMA. 2016;316:1279–1288. DOI: 10.1001/jama.2016.13647.
    1. Ribo M, Molina CA, Cobo E, Cerda N, Tomasello A, Quesada H, De Miquel MA, Millan M, Castano C, Urra X, et al. Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion. Stroke. 2016;47:999–1004. DOI: 10.1161/STROKEAHA.115.011721.
    1. Stein LK, Tuhrim S, Fifi J, Mocco J, Dhamoon MS. Interhospital transfers for endovascular therapy for acute ischemic stroke. Stroke. 2019;50:1789–1796. DOI: 10.1161/STROKEAHA.119.024869.
    1. Seo KD, Suh SH. Endovascular treatment in acute ischemic stroke: a nationwide survey in Korea. Neurointervention. 2018;13:84–89. DOI: 10.5469/neuroint.2018.01053.
    1. Chalos V, LeCouffe NE, Uyttenboogaart M, Lingsma HF, Mulder M, Venema E, Treurniet KM, Eshghi O, van der Worp HB, van der Lugt A, et al. Endovascular treatment with or without prior intravenous alteplase for acute ischemic stroke. J Am Heart Assoc. 2019;8:e011592. DOI: 10.1161/JAHA.118.011592.
    1. Rothwell PM. External validity of randomised controlled trials: "To whom do the results of this trial apply?" Lancet. 2005;365:82–93. DOI: 10.1016/S0140-6736(04)17670-8.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi