Acta Neurol Scand 2015: 131: 329–335 DOI: 10.1111/ane.12338
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA
Strokes in the anterior circulation: comparison between bridging and intravenous thrombolysis Sztajzel RF, Muller H, Sekoranja L, Viaccoz A, Mendez Pereira V, Narata AP, Lovblad K, Altrichter S, Michel P. Strokes in the anterior circulation: comparison between bridging and intravenous thrombolysis. Acta Neurol Scand 2015: 131: 329–335. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Background and purpose – To compare safety and efficacy of bridging approach with intravenous (IV) thrombolysis in patients with acute anterior strokes and proximal occlusions. Patients and methods – Consecutive patients with ischemic anterior strokes admitted within a 4 h 30 min window in two different centers were included. The first center performed IV therapy (alteplase 0.6 mg/kg) during 30 min and, in absence of clinical improvement, mechanical thrombectomy with flow restoration using a Solitaire stent (StS); the second carried out IV thrombolysis (alteplase 0.9 mg/kg) alone. Only T, M1 or M2 occlusions present on CT angiography were considered. Endpoints were clinical outcome and mortality at 3 months. Results – There were 63 patients in the bridging and 163 in the IV group. No significant differences regarding baseline characteristics were observed. At 3 months, 46% (n = 29) of the patients treated in the combined and 23% (n = 38) of those treated in the IV group had a modified Rankin scale (mRS) of 0–1 (P < 0.001). A statistical significant difference was observed for all sites of occlusion. In a logistic regression model, National Institute of Health Stroke Scale (NIHSS) and bridging therapy were independent predictors of good outcome (respectively, P = 0.001 and P = 0.0018). Symptomatic hemorrhage was documented in 6.3% vs 3.7% in the bridging and in the IV group, respectively (P = 0.32). There was no difference in mortality. Conclusions – Our results suggest that patients treated with a bridging approach were more likely to have minimal or no deficit at all at 3 months as compared to the IV treated group.
Introduction
Current acute ischemic stroke interventions aim to recanalize occluded arteries to restore cerebral blood flow (1). Intravenous (IV) thrombolysis with tissue type plasminogen activator (tPA) is well documented (1–3). Alternative strategies include entirely endovascular (pharmacological or mechanical) or bridging (IV/pharmacological/ mechanical) therapies (4–6). IV thrombolysis (0.9 mg/kg) is recommended as the first-line therapy for patients with acute ischemic stroke
R. F. Sztajzel1, H. Muller1, L. Sekoranja1, A. Viaccoz1, V. Mendez Pereira2, A. P. Narata2, K. Lovblad2, S. Altrichter2, P. Michel3 1 Department of Neurology, Medical School, University Hospitals of Geneva, Geneva, Switzerland; 2 Department of Radiology, Medical School, University Hospitals of Geneva, Geneva, Switzerland; 3 Department of Neurology, Medical School, University Hospitals of Lausanne, Lausanne, Switzerland
Key words: bridging therapy; intravenous thrombolysis; ischemic stroke; mechanical thrombectomy; proximal acute anterior circulation occlusions R. F. Sztajzel, Neurovascular Unit, Department of Neurology, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland Tel.: +41223728310 Fax: +41223728332 e-mail: [email protected] Accepted for publication September 24, 2014
presenting within 4.5 h of symptom onset (2, 3). However, with IV thrombolysis, chances of successful recanalization are low for proximal large artery occlusions (7–9). For instance, a rate of angiographic recanalization of 9% for T, of 35% for M1, and 54% for M2 segments of the middle cerebral artery (MCA) occlusions has been reported (9). Also, after analysis for stroke severity, the benefit of IV thrombolysis declines with increasing National Institute of Health Stroke Scale (NIHSS) scores (10, 11). Therefore, to improve recanalization in acute stroke, other 329
Sztajzel et al. strategies have been developed. Pharmacological and/or mechanical endovascular approaches have shown higher recanalization rates of up to 71% for T and 84% for the M1 segments of the MCA occlusions (12–17). However, because of potential time delay of primarily endovascular approaches which in turn may tend to minimize their potential advantage, bridging therapies have become an important part of the therapeutic protocols in the daily practice of several stroke centers (5, 6, 18–26). Indeed, bridging therapies consist in a combination of IV/pharmacological and mechanical thrombolysis. In fact, this type of therapy has a theoretical gain by combining rapid treatment initiation with IV tPA to endovascular techniques with higher recanalization rates. Also, it may be used either as rescue treatment in case of unsuccessful IV thrombolysis or as a direct treatment with the endovascular procedure beginning as fast as possible after the start of IV thrombolysis (18–22). Whether a higher recanalization rate reported with endovascular treatment may be translated into a better clinical outcome, it is still a matter of debate. Several clinical trials have explored the role of bridging therapy. Most of these studies used either intra-arterial (IA) tPA or mechanical devices such as Merci (MD) or Penumbra (PD) (13–16). Hence, more recent devices such as the Solitaire stent (StS) have been only marginally included in these studies (24). Also, sites of occlusion assessed radiologically have not been systematically compared side-by-side and evaluated with each therapeutic procedure. The aim of the present work was to compare safety and efficacy of a bridging approach using Solitaire stent (StS) with IV thrombolysis in patients with acute anterior strokes with proximal occlusions treated in two different centers. Patients and methods Patient cohort
All consecutive patients with ischemic anterior strokes admitted within a 4 h 30 min window in two different stroke centers were prospectively collected during the period of 2009–2012 for the bridging therapy and during the period of 2004– 2011 for IV therapy alone.
tory. Only strokes with T, M1, and M2 occlusions confirmed by CT scan angiography (CTA) were considered for this analysis. Assessments of the occlusion site on CTA were performed in each center by an experienced neuroradiologist, unaware of the clinical data except of the ischemic event’s side. Hemorrhagic complications were defined according to ECASS II criteria (27). IV therapy
In one center, the preferred treatment was IV standard thrombolysis alone, using alteplase 0.9 mg/kg with a bolus of 10% (during 1 min). Bridging therapy
In the other center, the preferred approach was IV therapy during 30 min. A dose of tPA of 0.6 mg/ kg with a bolus of 15% (during 1 min) was administered during the first 30 min for all patients. In case of absence of clinical improvement defined by a reduction of the NIHSS of ≥4 points and a total NIHSS of
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA
Strokes in the anterior circulation: comparison between bridging and intravenous thrombolysis Sztajzel RF, Muller H, Sekoranja L, Viaccoz A, Mendez Pereira V, Narata AP, Lovblad K, Altrichter S, Michel P. Strokes in the anterior circulation: comparison between bridging and intravenous thrombolysis. Acta Neurol Scand 2015: 131: 329–335. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Background and purpose – To compare safety and efficacy of bridging approach with intravenous (IV) thrombolysis in patients with acute anterior strokes and proximal occlusions. Patients and methods – Consecutive patients with ischemic anterior strokes admitted within a 4 h 30 min window in two different centers were included. The first center performed IV therapy (alteplase 0.6 mg/kg) during 30 min and, in absence of clinical improvement, mechanical thrombectomy with flow restoration using a Solitaire stent (StS); the second carried out IV thrombolysis (alteplase 0.9 mg/kg) alone. Only T, M1 or M2 occlusions present on CT angiography were considered. Endpoints were clinical outcome and mortality at 3 months. Results – There were 63 patients in the bridging and 163 in the IV group. No significant differences regarding baseline characteristics were observed. At 3 months, 46% (n = 29) of the patients treated in the combined and 23% (n = 38) of those treated in the IV group had a modified Rankin scale (mRS) of 0–1 (P < 0.001). A statistical significant difference was observed for all sites of occlusion. In a logistic regression model, National Institute of Health Stroke Scale (NIHSS) and bridging therapy were independent predictors of good outcome (respectively, P = 0.001 and P = 0.0018). Symptomatic hemorrhage was documented in 6.3% vs 3.7% in the bridging and in the IV group, respectively (P = 0.32). There was no difference in mortality. Conclusions – Our results suggest that patients treated with a bridging approach were more likely to have minimal or no deficit at all at 3 months as compared to the IV treated group.
Introduction
Current acute ischemic stroke interventions aim to recanalize occluded arteries to restore cerebral blood flow (1). Intravenous (IV) thrombolysis with tissue type plasminogen activator (tPA) is well documented (1–3). Alternative strategies include entirely endovascular (pharmacological or mechanical) or bridging (IV/pharmacological/ mechanical) therapies (4–6). IV thrombolysis (0.9 mg/kg) is recommended as the first-line therapy for patients with acute ischemic stroke
R. F. Sztajzel1, H. Muller1, L. Sekoranja1, A. Viaccoz1, V. Mendez Pereira2, A. P. Narata2, K. Lovblad2, S. Altrichter2, P. Michel3 1 Department of Neurology, Medical School, University Hospitals of Geneva, Geneva, Switzerland; 2 Department of Radiology, Medical School, University Hospitals of Geneva, Geneva, Switzerland; 3 Department of Neurology, Medical School, University Hospitals of Lausanne, Lausanne, Switzerland
Key words: bridging therapy; intravenous thrombolysis; ischemic stroke; mechanical thrombectomy; proximal acute anterior circulation occlusions R. F. Sztajzel, Neurovascular Unit, Department of Neurology, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland Tel.: +41223728310 Fax: +41223728332 e-mail: [email protected] Accepted for publication September 24, 2014
presenting within 4.5 h of symptom onset (2, 3). However, with IV thrombolysis, chances of successful recanalization are low for proximal large artery occlusions (7–9). For instance, a rate of angiographic recanalization of 9% for T, of 35% for M1, and 54% for M2 segments of the middle cerebral artery (MCA) occlusions has been reported (9). Also, after analysis for stroke severity, the benefit of IV thrombolysis declines with increasing National Institute of Health Stroke Scale (NIHSS) scores (10, 11). Therefore, to improve recanalization in acute stroke, other 329
Sztajzel et al. strategies have been developed. Pharmacological and/or mechanical endovascular approaches have shown higher recanalization rates of up to 71% for T and 84% for the M1 segments of the MCA occlusions (12–17). However, because of potential time delay of primarily endovascular approaches which in turn may tend to minimize their potential advantage, bridging therapies have become an important part of the therapeutic protocols in the daily practice of several stroke centers (5, 6, 18–26). Indeed, bridging therapies consist in a combination of IV/pharmacological and mechanical thrombolysis. In fact, this type of therapy has a theoretical gain by combining rapid treatment initiation with IV tPA to endovascular techniques with higher recanalization rates. Also, it may be used either as rescue treatment in case of unsuccessful IV thrombolysis or as a direct treatment with the endovascular procedure beginning as fast as possible after the start of IV thrombolysis (18–22). Whether a higher recanalization rate reported with endovascular treatment may be translated into a better clinical outcome, it is still a matter of debate. Several clinical trials have explored the role of bridging therapy. Most of these studies used either intra-arterial (IA) tPA or mechanical devices such as Merci (MD) or Penumbra (PD) (13–16). Hence, more recent devices such as the Solitaire stent (StS) have been only marginally included in these studies (24). Also, sites of occlusion assessed radiologically have not been systematically compared side-by-side and evaluated with each therapeutic procedure. The aim of the present work was to compare safety and efficacy of a bridging approach using Solitaire stent (StS) with IV thrombolysis in patients with acute anterior strokes with proximal occlusions treated in two different centers. Patients and methods Patient cohort
All consecutive patients with ischemic anterior strokes admitted within a 4 h 30 min window in two different stroke centers were prospectively collected during the period of 2009–2012 for the bridging therapy and during the period of 2004– 2011 for IV therapy alone.
tory. Only strokes with T, M1, and M2 occlusions confirmed by CT scan angiography (CTA) were considered for this analysis. Assessments of the occlusion site on CTA were performed in each center by an experienced neuroradiologist, unaware of the clinical data except of the ischemic event’s side. Hemorrhagic complications were defined according to ECASS II criteria (27). IV therapy
In one center, the preferred treatment was IV standard thrombolysis alone, using alteplase 0.9 mg/kg with a bolus of 10% (during 1 min). Bridging therapy
In the other center, the preferred approach was IV therapy during 30 min. A dose of tPA of 0.6 mg/ kg with a bolus of 15% (during 1 min) was administered during the first 30 min for all patients. In case of absence of clinical improvement defined by a reduction of the NIHSS of ≥4 points and a total NIHSS of
