Rescue Thrombectomy in Large Vessel Occlusion Strokes Leads to Better Outcomes than Intravenous Thrombolysis Alone: A 'Real World' Applicability of the Recent Trials

Raul G Nogueira; Osama O Zaidat; Alicia C Castonguay; Diogo C Haussen; Coleman O Martin; William E Holloway; Nils Mueller-Kronast; Joey English; Italo Linfante; Guilherme Dabus; Tim W Malisch; Franklin A Marden; Hormozd Bozorgchami; Andrew Xavier; Ansaar T Rai; Michael T Froehler; Aamir Badruddin; Thanh N Nguyen; M Asif Taqi; Michael G Abraham; Vallabh Janardhan; Albert J Yoo; Hashem Shaltoni; Alex Abou-Chebl; Peng R Chen; Gavin W Britz; Roberta Novakovic; Ashish Nanda; Ritesh Kaushal; Mohammad A Issa; Michael R Frankel; Rishi Gupta

doi:10.1159/000445809

Rescue Thrombectomy in Large Vessel Occlusion Strokes Leads to Better Outcomes than Intravenous Thrombolysis Alone: A 'Real World' Applicability of the Recent Trials

Interv Neurol. 2016 Sep;5(3-4):101-110. doi: 10.1159/000445809. Epub 2016 May 27.

Authors

Raul G Nogueira¹, Osama O Zaidat², Alicia C Castonguay², Diogo C Haussen¹, Coleman O Martin³, William E Holloway³, Nils Mueller-Kronast⁴, Joey English⁵, Italo Linfante⁶, Guilherme Dabus⁶, Tim W Malisch⁷, Franklin A Marden⁷, Hormozd Bozorgchami⁸, Andrew Xavier⁹, Ansaar T Rai¹⁰, Michael T Froehler¹¹, Aamir Badruddin¹², Thanh N Nguyen¹³, M Asif Taqi¹⁴, Michael G Abraham¹⁵, Vallabh Janardhan¹⁶, Albert J Yoo¹⁶, Hashem Shaltoni¹⁷, Alex Abou-Chebl¹⁸, Peng R Chen¹⁹, Gavin W Britz²⁰, Roberta Novakovic²¹, Ashish Nanda²², Ritesh Kaushal²³, Mohammad A Issa², Michael R Frankel¹, Rishi Gupta²⁴

Affiliations

¹ Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA.
² Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA.
³ St. Luke's Neuroscience Institute, Kansas City, Mo., USA.
⁴ Department of Neurology, Delray Medical Center, Delray Beach, Fla., USA.
⁵ California Pacific Medical Center, San Francisco, Calif., USA.
⁶ Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Fla., USA.
⁷ Alexian Brothers Medical Center, Elk Grove Village, Ill., USA.
⁸ Oregon Health and Sciences, Portland, Oreg., USA.
⁹ Department of Neurology, Wayne State University School of Medicine, Detroit, Mich., USA.
¹⁰ Department of Radiology, West Virginia University Hospital, Morgantown, W.Va., USA.
¹¹ Department of Neurology, Neurosurgery, and Radiology, Vanderbilt University Medical Center, Nashville, Tenn., USA.
¹² Department of Neurosurgery, Presence Saint Joseph Medical Center, Joliet, Ill., USA.
¹³ Department of Neurology, Boston University School of Medicine, Boston, Mass., USA.
¹⁴ Desert Regional Medical Center, Palm Springs, Calif., USA.
¹⁵ University of Kansas Medical Center, Kansas City, Kans., USA.
¹⁶ Texas Stroke Institute, Dallas Fort-Worth Metroplex, Tex., USA.
¹⁷ Baylor College of Medicine, Houston, Tex., USA.
¹⁸ Department of Neurology, University of Louisville Medical School, Louisville, Ky., USA.
¹⁹ Department of Neurosurgery, University of Texas, Houston, Tex., USA.
²⁰ Department of Neurosurgery, Methodist Neurological Institute, Houston, Tex., USA.
²¹ Department of Radiology and Neurology, UT Southwestern Medical Center, Dallas, Tex., USA.
²² University of Missouri, Columbia, Mo., USA.
²³ Saint Louis University, St. Louis, Mo., USA.
²⁴ Department of Neurosurgery, Wellstar Medical Group, Marietta., USA.

Abstract

Background: The Interventional Management of Stroke III (IMS-III) trial demonstrated no benefit for intravenous recombinant tissue plasminogen activator (IV rt-PA) followed by endovascular therapy versus IV rt-PA alone. However, IMS-III mostly included earlier generation devices. The recent thrombectomy trials have incorporated the stent-retriever technology, but their generalizability remains unknown.

Methods: The North American Solitaire Acute Stroke (NASA) registry recruited patients treated with the Solitaire FR™ device between March 2012 and February 2013. The NASA-IMS-III-Like Group (NILG baseline NIHSS score ≥10 who received IV rt-PA) was compared to the IV rt-PA and IV + intra-arterial (IA)-IMS-III groups and the MR CLEAN, ESCAPE, SWIFT Prime, and REVASCAT trial controls to assess the stent-retriever treatment in the 'real-world' setting. The NILG was also compared to non-IV rt-PA NASA patients to evaluate the impact of IV rt-PA on thrombectomy.

Results: A total of 136 of the 354 NASA patients fulfilled criteria for the NILG. Baseline characteristics were well balanced across groups. Time from onset to puncture was higher in NILG than IV+IA-IMS-III patients (274 ± 112 vs. 208 ± 47 min, p < 0.0001). Occlusions involving the intracranial ICA, MCA-M1, or basilar arteries were more common in NILG than IV+IA-IMS-III patients (91.2 vs. 47.2%, p < 0.00001). Modified thrombolysis in cerebral infarction ≥2b reperfusion was higher in NILG than IV+IA-IMS-III patients (74.3 vs. 39.6%, p < 0.00001). A 90-day modified Rankin Scale score ≤2 was more frequent in the NILG than IV+IA-IMS-III patients (51.9 vs. 40.8%, p = 0.03) and MR CLEAN (51.9 vs. 19.1%, p < 0.00001), ESCAPE (51.9 vs. 29.3%, p = 0.0002), SWIFT Prime (51.9 vs. 35.5%, p = 0.02), and REVASCAT (51.9 vs. 28.2%, p = 0.0003) controls. Symptomatic intracranial hemorrhage definitions varied across the different studies with rates ranging from 2.7% (ESCAPE) to 11.9% (NILG). The NILG 90-day mortality (24.4%) was higher than in SWIFT Prime but comparable to all other groups. IV rt-PA was an independent predictor of good outcome in NASA (OR = 2.3, 95% CI 1.2-4.7).

Conclusion: Our results support the 'real-world' applicability of the recent thrombectomy trials.

Keywords: Interventional Management of Stroke III trial; Intravenous thrombolysis; Large vessel occlusion; Rescue thrombectomy.