Endovascular Thrombectomy with or Without Alteplase? Get With The Guidelines.

Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York Presbyterian/Weill Cornell Medical College

SOURCE: Smith EE, Zerna C, Solomon N, et al. Outcomes after endovascular thrombectomy with or without alteplase in routine clinical practice. JAMA Neurol 2022; Jun 13. doi:10.1001/jamaneurol.2022.1413. [Online ahead of print].

Since 2015, endovascular thrombectomy with intravenous alteplase has been the standard of care for patients with large vessel occlusion and ischemic stroke. However, since that time, the continuing use of alteplase has been questioned by many practitioners and investigators. The concern has been that the use of alteplase may increase the risk of bleeding and is not likely to result in recanalization before endovascular thrombectomy is completed.

Some practitioners have stated that administering intravenous thrombolysis delays treatment with endovascular thrombectomy. A number of clinical trials have been reported that have found small differences without evidence of superiority of either approach, and this remains a controversial topic among the stroke treatment community. Controversy also exists regarding appropriate triage of ambulances carrying patients with acute ischemic stroke to reach a thrombectomy-capable center as quickly as possible. Treatment with intravenous thrombolysis at a primary stroke center followed by transfer to a thrombectomy-capable center may delay definitive treatment. In spite of these questions, standard guidelines for the management of ischemic stroke include intravenous alteplase for all eligible patients.

To help answer this question, the investigators undertook a review of all adult patients with acute ischemic stroke treated with endovascular thrombectomy within six hours of last known well time. Patients were participants in the Get With The Guidelines stroke registry, which included 555 hospitals in the United States. They designed an observational cohort study, collecting data from Feb. 1, 2019, until June 30, 2020. They looked at eight pre-specified outcomes in these patients, including discharge destination, independent ambulation at discharge, modified Rankin scale score at discharge, discharge mortality, cerebral perfusion according to modified Thrombolysis in Cerebral Infarction (TICI) grade, and symptomatic intracerebral hemorrhage.

Review of the database revealed 15,832 patients treated with endovascular thrombectomy. Fifty percent were women, and 66.7% received alteplase. Patients treated with alteplase had less comorbidity, such as atrial fibrillation, hypertension, and diabetes, and also were younger. Patients treated with alteplase arrived at the hospital by ambulance sooner than those who were not treated with alteplase.

However, the patients had similar National Institutes of Health Stroke Scale severity scores. Patients treated with alteplase had lower mortality (11.1% vs. 13.9%) and were more likely to have no major disability based on a modified Rankin scale score of 2 or less on discharge (28.5% vs. 20.7%). Patients treated with alteplase had better reperfusion. However, alteplase treatment was associated with a higher risk of symptomatic intracerebral hemorrhage (6.5% vs. 5.3%).

The investigators’ conclusion was that intravenous alteplase treatment along with endovascular thrombectomy was associated with better in-hospital survival and functional outcomes with a higher, but small, increase in risk of symptomatic intracerebral hemorrhage.