A Moving Target? The Fate of Large Vessel Occlusion Strokes Pretreated with Intravenous Tissue Plasminogen Activator in the Era of Mechanical Thrombectomy

2020 ◽  
Vol 141 ◽  
pp. e447-e452 ◽  
Author(s):  
Gary Rajah ◽  
Hamidreza Saber ◽  
Bryan Lieber ◽  
Ari Kappel ◽  
Marisa Smitt ◽  
...  
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Moving Target ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

scholarly journals Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of “Drip and Ship” on Effectiveness and Outcomes

2020 ◽  
Vol 11 ◽  
Author(s):  
Adam Chang ◽  
Elham Beheshtian ◽  
Edward J. Llinas ◽  
Oluwatoyin R. Idowu ◽  
Elisabeth B. Marsh
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Hemorrhagic Transformation ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
The Impact ◽  
Iv Tpa

Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital.Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes.Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h.Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.

Abstract WP111: The Role of Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Yinn Cher Ooi ◽  
Faisal Mukarram ◽  
Honda Tristan ◽  
Naoki Kaneko ◽  
May Nour ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Large Vessel Occlusion ◽  
Access Site ◽  
Vessel Occlusion ◽  
Stroke Outcomes ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

Introduction: Current guidelines recommend administration of intravenous tissue plasminogen activator (IVT) for all eligible patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO). Recent observational data question the safety and efficacy of IVT in AIS patients with LVO undergoing mechanical thrombectomy (MT). Methods: Retrospective analysis using prospectively collected database on all AIS patients with LVO treated at our institution over 3 consecutive years. Stroke outcomes and adverse events were compared between patients who underwent IVT+MT versus MT only. Stroke outcomes were adjusted for known comorbidities, last know well time and core volume on pretreatment imaging. Results: 158 AIS patients with LVO were treated. 69 patients had treatment strategy of IVT+MT, 89 patients MT only. 7 (10%) patients treated with IVT had successful reperfusion before MT. IVT+MT, compared with MT alone, was associated with reduced 90day mortality (22.4% vs 40.8%, p:0.03) and reduced 90day severe disability or death (mRS 4-6: 48% vs 67%, p:0.03). Door-to-puncture time (DTP) was longer with IVT. IVT was not associated with increased intracranial hemorrhage but was associated with increased access site hematomas (16.9% vs 5.7%, p:0.03). Both groups showed similar proportion of patients ≥TICI2c (IVT+MT: 48% vs MT: 47%), however IVT+MT patients had greater proportion of TICI2c than TICI3. (IVT+MT TICI2c:30.4% vs MT TICI2c:17%) Conclusions: IVT before MT in AIS with LVO, results in reperfusion prior to thrombectomy in 10% of patients, and is associated with reduced mortality and severe disability at 90days. However, IVT+MT is associated with more access site hematomas and increased TICI 2C vs TICI 3 reperfusion, suggesting increased distal embolization due to thrombus fragmentation. The use of balloon guide for proximal flow arrest and aspiration during thrombectomy should be considered.

Abstract T P1: Predictive Factors of Intracranial Hemorrhage in Patients With Acute Large Vessel Occlusion

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Yukiko Enomoto ◽  
Shinichi Yoshimura ◽  
Yusuke Egashira ◽  
Hiroshi Yamagami ◽  
Nobuyuki Sakai ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Predictive Factors ◽  
Statistical Significance ◽  
Large Vessel ◽  
Related Factor ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Major Vessel ◽  
Tissue Plasminogen

Objective: Recanalization therapy, such as intravenous tissue plasminogen activator (IVT) or endovascular treatment (EVT), is known to improve outcomes in acute ischemic stroke; however, such maneuver carries the risk of intracranial hemorrhage (ICH). The present study assessed the predictive factors of ICH in the patients with acute large vessel occlusion. Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan registry prospectively registered 1,442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset from July 2010 to June 2011. We analyzed the incidence and predictive factor of ICH within 24 hours after onset among the 1,436 patients except 6 patients who underwent bypass surgery. Results: Any ICH was observed in 283 (19.7%) patients, and symptomatic (with neurological deterioration defined as National Institute of Health Stroke Scale score ≥4) ICH was observed in 47 (3.3%) patients. Comparing patients without ICH, we find statistical significance in the rate of favorable outcome (any ICH; 18.3% vs. 35.0%, p<0.001, symptomatic ICH; 4.3% vs. 32.6%, p<0.001). On multivariate analyses, any recanalization therapy (IVT and/or EVT)(OR, 1.94; 95% CI, 1.09-3.44)and reperfusion of the affected artery on MR angiography at 24 hours after onset (OR, 1.90; 95% CI, 1.31-2.75) significantly related to any ICH. Significant related factor of symptomatic ICH was only recanalization therapy (OR, 2.45; 95% CI; 1.30-4.16), but not EVT (OR; 1.26; 95% CI, 0.50-3.16). Moreover, warfarin-, antiplatelet-, heparin- or thrombolytic agents-use was not an independent predictor of ICH risk. Conclusions: Among the patients with acute large vessel occlusion, ICH was associated with recanalization therapy (IVT or EVT), but not the use of antithrombotic agents.

Risk Factors for Distal Clot Migration during Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusion

2020 ◽  
Vol 49 (2) ◽  
pp. 185-191 ◽  
Author(s):  
Mahmoud H. Mohammaden ◽  
Christopher J. Stapleton ◽  
Denise Brunozzi ◽  
Eman M. Khedr ◽  
Peter Theiss ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Thrombectomy ◽  
Multivariable Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Multivariable Analyses ◽  
Iv Tpa

Introduction: Distal clot migration (DCM) is a known complication of mechanical thrombectomy (MT), but neither risk factors for DCM nor ways of how it might affect clinical outcomes have been extensively studied to date. Methods: To identify risk factors for and outcomes in the setting of DCM, the records of all patients with acute ischemic stroke due to anterior circulation large vessel occlusion (LVO) treated with MT at a single center between May 2016 and June 2018 were retrospectively reviewed. Uni- and multivariable analyses were performed to evaluate predictors of DCM and good functional outcome (90-day modified Rankin Scale; mRS 0–2). Results: A total of 65 patients were included, DCM was identified in 22 patients (33.8%). Patients with DCM had significantly higher pre-procedural intravenous tissue plasminogen activator (IV-tPA) administration (81.8 vs. 53.5%, p = 0.03), stentrievers thrombectomy (95.5 vs. 62.8%, p = 0.006), and longer median puncture to recanalization time (44 [34–97] vs. 30 [20–56] min, p = 0.028) as compared to group with non-DCM. Also, they had lower rates of Thrombolysis in Cerebral Infarction (TICI) 2b/3 recanalization (p = 0.002), higher median National Institutes of Health Stroke Scale (NIHSS) scores at discharge (p = 0.01), and lower rates of 90-day mRS (0–2; 18.2 vs. 48.8%; p = 0.016). On subgroup analysis, patients with middle cerebral artery occlusions who underwent MT with stentrievers <40 mm in length had a higher risk of DCM (p = 0.026). On multivariable analysis, IV-tPA administration (OR; 5.019, 95% CI [1.319–19.102], p = 0.018) and stentrievers thrombectomy (OR; 10.031, 95% CI [1.090–92.344]; p = 0.04) remained significant predictors of DCM. Baseline NIHSS score (OR; 0.872, 95% CI [0.788–0.965], p = 0.008) and DCM (OR; 0.250, 95% CI [0.075–0.866], p = 0.03) were independent predictors of 90-day mRS 0–2. Conclusion: In patients undergoing MT for anterior circulation LVO, DCM is associated with lower rates of TICI 2b/3 recanalization and worse functional outcomes at 90 days. IV-tPA administration and MT with short stentrievers are independent predictors of DCM development.

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