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Thrombectomy alone vs. Thrombectomy plus thrombolysis

Synthesis

Dashboard

Qualitative

Quantitative

Critical Appraisal

PRISMA

Abstract

Gautam Adusumilli, Kevin Kallmes, Kristen Hutchison, Nicole Hardy, Kathryn Cowie, Daniel Heiferman, Jeremy J HeitLast Edited: 2022-09-26

Background: Mechanical thrombectomy (MT) is now the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation and may be performed irrespectiveof intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure. This study aims to understand better if tPA leads to higher rates of reperfusion andimproves functional outcomes in AIS patients after MT and to simultaneously evaluatethe functionality and efficiency of a novel semi-automated systematic review platform.Methods: The Nested Knowledge AutoLit semi-automated systematic review platformwas utilized to identify randomized control trials published between 2010 and 2021reporting the use of mechanical thrombectomy and IV-tPA (MT+tPA) vs. MT alone forAIS treatment. The primary outcome was the rate of successful recanalization, definedas thrombolysis in cerebral infarction (TICI) scores ≥2b. Secondary outcomes included90-day modified Rankin Scale (mRS) 0–2, 90-day mortality, distal embolization to newterritory, and symptomatic intracranial hemorrhage (sICH). A separate random effectsmodel was fit for each outcome measure.Results: We subjectively found Nested Knowledge to be highly streamlined and effectiveat sourcing the correct literature. Four studies with 1,633 patients, 816 in the MT+tPAarm and 817 in the MT arm, were included in the meta-analysis. In each study, patientpopulations consisted of only tPA-eligible patients and all imaging and clinical outcomeswere adjudicated by an independent and blinded core laboratory. Compared to MT alone,patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10;1.63]). However, there were no statistically significant differences in the rates of 90-daymRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67;1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI:0.80; 1.72]).Conclusions: Administering tPA prior to MT may improve the rates of recanalizationcompared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in this review. Furtherstudies looking at the role of tPA before mechanical thrombectomy in different cohortsof patients could better clarify the role of tPA in the treatment protocol for AIS.

Study information:

PMID: 34975722

DOI: 10.3389/fneur.2021.759759

Key Insights:

No significant difference in 90-day mRS 0-2, sICH, 90-day mortality or distal emboli

There were no statistically significant differences in the rates of 90-day mRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67; 1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI: 0.80; 1.72]).

Lack of specification of device type

None of the papers broke down the data by the device used (stentriever, aspiration, combination). As shown by Colby, et al, the types of devices used in MT can affect the first pass successful recanalization rate. (Colby, Geoffrey P et al. “Increased Success of Single-Pass Large Vessel Recanalization Using a Combined Stentriever and Aspiration Technique: A Single Institution Study.” World neurosurgery vol. 123 (2019): e747-e752. doi:10.1016/j.wneu.2018.12.023). Therefore, it is a limitation that none of these studies reported the outcomes by device type.

MT + IV-tPA significantly increases successful recanalization over MT alone

Compared to MT alone, patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10; 1.63]).