[en] [en] OBJECTIVE: Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT.
METHODS: The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture.
RESULTS: Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709).
INTERPRETATION: In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.
Disciplines :
Neurology
Author, co-author :
Gory, Benjamin ; Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France ; INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France
Finitsis, Stephanos; Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
Olivot, Jean-Marc ; Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
Richard, Sébastien; Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France ; CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
Marnat, Gaultier; Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
Sibon, Igor; Neurology Department, University Hospital of Bordeaux, Bordeaux, France
Viguier, Alain; Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
Cognard, Christophe; Department of Neuroradiology, Toulouse, France
Mazighi, Mikael; Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France ; Department of Neurology, Hôpital Lariboisière, Paris, France ; Université Paris-Cité, Paris, France ; Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
Chamorro, Angel ; Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
Lapergue, Bertrand; Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
Maïer, Benjamin; Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France ; Université Paris-Cité, Paris, France ; Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France ; Department of Neurology, Hôpital Saint-Joseph, Paris, France
Endovascular Treatment in Ischemic Stroke Registry Investigators
J.\u2010M.O. declares consulting activities with Abbvie, Acticor and Bioxodes; and speaking fees from BMS and Boehringer Ingelheim. S.F. is the author of a patent (US20200085454A1). B.M. declares a grant from the French Health Ministry and is the primary investigator of the DETERMINE trial. B.G. has received grants from the French Ministry of Health, is the primary investigator of the TITAN, DIRECT ANGIO, and IA\u2010SUCCESS trials, and has received consulting fees from Air Liquide, MIVI, Medtronic, Microvention, and Penumbra. M.M. declares consulting fees from Boehringer Ingelheim, Air Liquide, Acticor Biotech, and Amgen. S.R. declares contracts from Boehringer Ingelheim France, Bristol Myers Squibb, and Pfizer.
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