Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy : A Matched Case-control Analysis from the German Stroke Registry

Egon Burian, Dominik Sepp, Manuel Lehm, Kathleen Bernkopf, Silke Wunderlich, Isabelle Riederer, Christian Maegerlein, Anna Alegiani, Claus Zimmer, Tobias Boeckh-Behrens, GSR-ET Investigators, Egon Burian, Dominik Sepp, Manuel Lehm, Kathleen Bernkopf, Silke Wunderlich, Isabelle Riederer, Christian Maegerlein, Anna Alegiani, Claus Zimmer, Tobias Boeckh-Behrens, GSR-ET Investigators

Abstract

Objective: Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity.

Methods: Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients' baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration.

Results: In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006).

Conclusion: The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures.

Keywords: Acute ischemic stroke; Alteplase; Anterior circulation; Brain infarction; Brain revascularization.

Conflict of interest statement

T. Boeckh-Behrens received speaker honoraria from Philips, Microvention and Phenox and reports consultancy fees from Microvention outside of the submitted work. C. Zimmer disclosed no relevant relationships regarding activities related to the present article. He has served on scientific advisory boards for Philips and Bayer Schering; serves as co-editor on the Advisory Board of Clinical Neuroradiology; has received speaker honoraria from Bayer-Schering and Philips; the institution has received research support and investigator fees for clinical studies from Biogen Idec, Quintiles, MSD Sharp & Dome, Boehringer Ingelheim, Inventive Health Clinical UK Ltd., Advance Cor, Brainsgate, Pfizer, Bayer-Schering, Novartis, Roche, Servier, Penumbra, WCT GmbH, Syngis, SSS International Clinical Research, PPD Germany GmbH, Worldwide Clinical Trials Ltd., Phenox, Covidien, Actelion, Medivation, Medtronic, Harrison Clinical Research, Concentric, Pharmtrace, Reverse Medical Corp., Premier Research Germany Ltd., Surpass Medical Ltd., GlaxoSmithKline, AXON Neuroscience, Bristol-Myers Squibb, Genentech, Acandis, EISAI, NeuroRx, Italfarmaco, Bioclinica, MIAC and IXICO. No patents issued and pending. E. Burian, D. Sepp, M. Lehm, K. Bernkopf, S. Wunderlich, I. Riederer, C. Maegerlein, and A. Alegiani declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Flowchart showing the cohort composition and matching procedure. ASPECTS Alberta Stroke Program Early CT Score, IVT Intravenous thrombolysis, MT Mechanical thrombectomy, NIHSS National Institutes of Health Stroke Scale
Fig. 2
Fig. 2
In this shift analysis the distribution of modified Rankin Scale score at day 90 is shown. a Includes the initial unmatched cohort, b cohort after first matching step, c cohort after second matching step. IVT Intravenous thrombolysis, MT Mechanical thrombectomy

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