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Alteplase before endovascular treatment is recommended over endovascular treatment alone for acute ischemic strokes
Clinical Question
Is endovascular treatment alone as effective as intravenous alteplase plus endovascular treatment for patients with acute ischemic strokes?
Bottom line
For patients presenting with acute anterior circulation strokes, endovascular treatment alone is not as effective as endovascular treatment preceded by intravenous alteplase. Despite the concern for increased bleeding with alteplase, the 2 regimens have similar safety outcomes. 1b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Industry + govt
Setting: Inpatient (any location)
Synopsis
For this multicenter, open-label trial from Europe, investigators enrolled patients who presented to the emergency department with acute anterior circulation ischemic strokes. Eligible patients were those who presented within 4.5 hours of symptom onset, qualified for endovascular treatment (EVT) and intravenous alteplase, and were admitted to hospitals capable of performing both. Patients were randomized to receive alteplase followed by EVT (n = 273) or EVT alone (n = 266). The median age of the overall group was 71 years, 57% were men, and the median National Institutes of Health Stroke Scale score was 16. The primary outcome was degree of disability based on the modified Rankin scale (0 to 6; 0 = no disability, 6 = death). At 90 days, patients in the EVT-alone group trended toward more disability than the alteplase-plus-EVT group (modified Rankin score of 3 vs 2); however, the adjusted odds ratio and confidence interval showed no statistically significant difference between the 2 groups (odds ratio [OR] 0.84; 95% CI 0.62 - 1.15; P = .28). EVT alone also did not meet pre-specified criteria for noninferiority when compared with the combination therapy. Additionally, there were no significant differences in 90-day mortality (20.5% in EVT alone vs 15.8%; OR 1.39; 0.84 - 2.30) or symptomatic intracerebral hemorrhages (5.9% in EVT alone vs 5.3%; OR 1.30; 0.60 - 2.81) between the 2 groups.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
EVT vs alteplase + EVT
Without repeating the numbers the conclusion in the abstract of the original study states, "EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke." The title of the study is, "A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke". How on earth does this translate into the title of this daily POEM as, "Alteplase before endovascular treatment is recommended over endovascular treatment alone for acute ischemic strokes."? These is either disingenuous, a biased POEM title, or a or a complete misapplicaiton of the results of the article either the by reviewer or the publisher. The POEM title should be retracted and re-issued with a title that accurately reflects the science.
no
new info
EVT vs EVT plus rTPA in anterior circulation stroke
Interesting to know. We often debate whether to send patients for EVT vs thrombolysing before transfer.
alteplase before endovasc treatment
more successful for treating anterior circ strokes