Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial.
extracranial stent
intravenous thrombolysis
mechanical thrombectomy
randomized controlled trial
tandem lesion
Journal
European journal of neurology
ISSN: 1468-1331
Titre abrégé: Eur J Neurol
Pays: England
ID NLM: 9506311
Informations de publication
Date de publication:
26 Feb 2024
26 Feb 2024
Historique:
revised:
26
01
2024
received:
21
11
2023
accepted:
07
02
2024
medline:
27
2
2024
pubmed:
27
2
2024
entrez:
27
2
2024
Statut:
aheadofprint
Résumé
The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
Sections du résumé
BACKGROUND AND PURPOSE
OBJECTIVE
The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting.
METHODS
METHODS
SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes.
RESULTS
RESULTS
Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05).
CONCLUSIONS
CONCLUSIONS
No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e16256Subventions
Organisme : Medtronic Inc.
Informations de copyright
© 2024 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.
Références
Papanagiotou P, Haussen DC, Turjman F, et al. Carotid stenting with antithrombotic agents and intracranial thrombectomy leads to the highest recanalization rate in patients with acute stroke with tandem lesions. JACC Cardiovasc Interv. 2018;11(13):1290-1299. doi:10.1016/j.jcin.2018.05.036
Zhu F, Bracard S, Anxionnat R, et al. Impact of emergent cervical carotid stenting in tandem occlusion strokes treated by thrombectomy: a review of the TITAN collaboration. Front Neurol. 2019;10(March):1-6. doi:10.3389/fneur.2019.00206
Anadani M, Marnat G, Consoli A, et al. Endovascular therapy of anterior circulation tandem occlusions: pooled analysis from the TITAN and ETIS registries. Stroke. 2021;52(October):3097-3105. doi:10.1161/STROKEAHA.120.033032
Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke. 2006;37(9):2301-2305. doi:10.1161/01.STR.0000237070.80133.1d
Thomalla G, Kruetzelmann A, Siemonsen S, et al. Clinical and tissue response to intravenous thrombolysis in tandem internal carotid artery/middle cerebral artery occlusion: an MRI study. Stroke. 2008;39(5):1616-1618. doi:10.1161/STROKEAHA.107.504951
Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke. 2005;36(4):869-871. doi:10.1161/01.STR.0000160007.57787.4c
Nogueira RG, Tsivgoulis G. Large vessel occlusion strokes after the DIRECT-MT and SKIP trials: is the alteplase syringe half empty or half full? Stroke. 2020;51(51):3182-3186. doi:10.1161/STROKEAHA.120.030796
Gory B, Haussen DC, Piotin M, et al. Impact of intravenous thrombolysis and emergent carotid stenting on reperfusion and clinical outcomes in patients with acute stroke with tandem lesion treated with thrombectomy: a collaborative pooled analysis. Eur J Neurol. 2018;25(9):1115-1120. doi:10.1111/ene.13633
Anadani M, Spiotta AM, Alawieh A, et al. Emergent carotid stenting plus thrombectomy after thrombolysis in tandem strokes: analysis of the TITAN registry. Stroke. 2019;50(8):2250-2252. doi:10.1161/STROKEAHA.118.024733
Anadani M, Marnat G, Consoli A, et al. Endovascular therapy with or without intravenous thrombolysis in acute stroke with tandem occlusion. J Neurointerv Surg. 2022;14(4):314-320. doi:10.1136/neurintsurg-2020-017202
Marnat G, Sibon I, Bourcier R, et al. Thrombolysis improves reperfusion and the clinical outcome in tandem occlusion stroke related to cervical dissection: TITAN and ETIS pooled analysis. J Stroke. 2021;23(3):411-419. doi:10.5853/jos.2020.04889
Fischer U, Kaesmacher J, Strbian D, et al. Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial. Lancet. 2022;400(10346):104-115. doi:10.1016/S0140-6736(22)00537-2
LeCouffe NE, Kappelhof M, Treurniet KM, et al. A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med. 2021;385(20):1833-1844. doi:10.1056/NEJMoa2107727
Mitchell PJ, Yan B, Churilov L, et al. Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial. Lancet. 2022;400(10346):116-125. doi:10.1016/S0140-6736(22)00564-5
Yang P, Zhang Y, Zhang L, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382(21):1981-1993. doi:10.1056/nejmoa2001123
Zi W, Qiu Z, Li F, et al. Effect of endovascular treatment alone vs intravenous Alteplase plus endovascular treatment on functional Independence in patients with acute ischemic stroke: the DEVT randomized clinical trial. JAMA. 2021;325(3):234-243. doi:10.1001/jama.2020.23523
Suzuki K, Matsumaru Y, Takeuchi M, et al. Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: the SKIP randomized clinical trial. JAMA. 2021;325(3):244-253. doi:10.1001/jama.2020.23522
Mujanovic A, Eker O, Marnat G, et al. Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial. J Neurointerv Surg. 2022;15:e232-e239. doi:10.1136/jnis-2022-019585
Von Kummer R, Broderick JP, Campbell BCV, et al. The heidelberg bleeding classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke. 2015;46(10):2981-2986. doi:10.1161/STROKEAHA.115.010049
Schandelmaier S, Briel M, Varadhan R, et al. Development of the instrument to assess the credibility of effect modification analyses (ICEMAN) in randomized controlled trials and meta-analyses. CMAJ. 2020;192(32):E901-E906. doi:10.1503/cmaj.200077
Turc G, Isabel C, Calvet D. Intravenous thrombolysis for acute ischemic stroke. Diagn Interv Imaging. 2014;95(12):1129-1133. doi:10.1016/j.diii.2014.10.002
Goyal M, Menon BK, Van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723-1731. doi:10.1016/S0140-6736(16)00163-X
Marnat G, Lapergue B, Sibon I, et al. Safety and outcome of carotid dissection stenting during the treatment of tandem occlusions: a pooled analysis of TITAN and ETIS. Stroke. 2020;51(December):3713-3718. doi:10.1161/STROKEAHA.120.030038
Grigoryan M, Haussen DC, Hassan AE, et al. Endovascular treatment of acute ischemic stroke due to tandem occlusions: large multicenter series and systematic review. Cerebrovasc Dis. 2016;41(5-6):306-312. doi:10.1159/000444069
Zapata-Arriaza E, de Albóniga-Chindurza A, Ortega-Quintanilla J, et al. Clinical outcomes of mechanical thrombectomy in stroke tandem lesions according to intracranial occlusion location. J Stroke. 2021;23(1):124-127. doi:10.5853/jos.2020.02747
Feil K, Herzberg M, Dorn F, et al. Tandem lesions in anterior circulation stroke: analysis of the German stroke registry-endovascular treatment. Stroke. 2021;52(April):1265-1275. doi:10.1161/STROKEAHA.120.031797
Ospel JM, Hill MD, Kappelhof M, et al. Which acute ischemic stroke patients are fast progressors?: results from the ESCAPE trial control arm. Stroke. 2021;52(5):1847-1850. doi:10.1161/STROKEAHA.120.032950
Meinel TR, Kaesmacher J, Buetikofer L, et al. Time to treatment with bridging intravenous alteplase before endovascular treatment: subanalysis of the randomized controlled SWIFT-DIRECT trial. J Neurointerv Surg. 2022;15:e102-e110. doi:10.1136/jnis-2022-019207
Curran-Everett D, Milgrom H. Post-hoc data analysis: benefits and limitations. Curr Opin Allergy Clin Immunol. 2013;13(3):223-224. doi:10.1097/ACI.0b013e3283609831
Wilson MP, Murad MH, Krings T, et al. Management of tandem occlusions in acute ischemic stroke-intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis. J Neurointerv Surg. 2018;10(8):721-728. doi:10.1136/neurintsurg-2017-013707