Mechanical Thrombectomy Outcomes With or Without Intravenous Thrombolysis

Insight From the ASTER Randomized Trial

Florent Gariel, MD, MSc; Bertrand Lapergue, MD, PhD; Romain Bourcier, MD, PhD; Jérôme Berge, MD; Xavier Barreau, MD; Mikael Mazighi, MD, PhD; Maéva Kyheng, BST; Julien Labreuche, BST; Robert Fahed, MD; Raphael Blanc, MD, MSc; Benjamin Gory, MD, PhD; Alain Duhamel, PhD; Suzana Saleme, MD; Vincent Costalat, MD, PhD; Serge Bracard, MD, PhD; Hubert Desal, MD, PhD; Lili Detraz, MD; Arturo Consoli, MD; Michel Piotin, MD, PhD; Gaultier Marnat, MD; for the ASTER Trial Investigators

Disclosures

Stroke. 2018;49(10):2383-2390. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Intravenous thrombolysis (IVT) within 4.5 hours of symptom onset is currently recommended before mechanical thrombectomy (MT). We compared functional outcome, neurological recovery, reperfusion, and adverse events according to the use or not of IVT before MT.

Methods: This is a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). The primary outcome was favorable 90-day functional outcome defined as a modified Rankin Scale of ≤2. Secondary outcomes were successful reperfusion following all procedures and after the first-line procedure, number of device passes, and change in National Institutes of Health Stroke Scale score at 24 hours. Safety outcomes included 90-day mortality and any symptomatic intracerebral hemorrhage.

Results: Three hundred eighty-one patients were included, 250 of whom received IVT before MT (IVT+MT group). There were no significant differences between IVT+MT and MT-alone groups in 90-day favorable functional outcome, in successful reperfusion rate (modified Thrombolysis In Cerebral Infarction 2b or 3), in National Institutes of Health Stroke Scale score improvement at 24 hours, or in hemorrhagic complication rate. The 90-day mortality rate in the IVT+MT group was lower than after MT alone (fully-adjusted risk ratio, 0.59; 95% CI, 0.39–0.88). In a subgroup of patients without anticoagulant medication before stroke onset, we observed in the IVT+MT group a better functional outcome (fully-adjusted risk ratio, 1.38; 95% CI, 1.02–1.89), a higher successful recanalization rate after first-line strategy (fully-adjusted risk ratio, 1.26; 95% CI, 1.05–1.50), and a lower mortality rate (fully-adjusted risk ratio, 0.58; 95% CI, 0.36–0.93).

Conclusions: Our results show that IVT+MT patients in the ASTER trial have lower 90-day mortality compared with those receiving MT alone. In a selected population of patients without prestroke anticoagulation, we demonstrated that IVT associated with MT might improve functional outcome and recanalization while reducing mortality rates.

Introduction

Six randomized controlled trials and an aggregate level analysis of their data have proven the superiority of mechanical thrombectomy (MT) over standard medical management alone after acute ischemic stroke because of large vessel occlusion.[1,2] Intravenous thrombolysis (IVT) within 4.5 hours is currently recommended before MT. Several studies suggested that IVT may influence recanalization rate and clinical outcome after MT.[3] However, its precise benefit remains under debate. IVT might be helpful, in particular, for cases of distal emboli after MT, but it may also increase the hemorrhagic complication rate. In addition, IVT could delay MT particularly in a drip-and-ship approach. To date, there is no randomized trial comparing MT after IVT versus MT alone.

The ASTER (Contact Aspiration vs Stent Retriever for Successful Revascularization) study[4] was a randomized clinical trial aiming to compare efficacy and safety of the contact aspiration (CA) technique versus the standard stent retriever (SR) technique. We performed a post hoc analysis to investigate the role and the safety of IVT, in cases of acute ischemic stroke caused by vessel occlusion, subsequently treated with MT within our ASTER trial population.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....