Abstract
Introduction
It is poorly understood if endovascular thrombectomy (EVT) with or without intravenous
thrombolysis (IVT) better facilitates clinical outcomes in patients with acute basilar
artery occlusion (BAO) ischemic stroke.
Methods
A systematic literature review and meta-analysis was completed to investigate the
outcomes of EVT with IVT versus direct EVT alone in acute BAO. Data was collected
from the literature and pooled with the authors’ institutional experience. The primary
outcome measure was 90-day modified Rankin sale (mRS) of 0-2. Secondary measures were
successful post-thrombectomy recanalization defined as mTICI ≥2b, 90-day mortality,
and rate of symptomatic ICH.
Results
Our institutional experience combined with three multicenter studies resulted in a
total of 1,127 patients included in the meta-analysis. 756 patients underwent EVT
alone, while 371 were treated with EVT+IVT. Patients receiving EVT+IVT had a higher
odds of achieving a 90-day mRS of ≤ 2 compared to EVT alone (OR: 1.50, 95% CI 1.15
to 1.95, P =0.002, I2 =0%). EVT+IVT also had a lower odds of 90-day mortality (OR: 0.57, 95% CI 0.37 to
0.89, P=0.01, I2=24%). There was no difference in sICH between the two groups (OR: 1.0, 95% CI: 0.56
to 1.79, P=0.99, I2=0%). There was also no difference in post-thrombectomy recanalization rates defined
as mTICI ≥2b (OR: 1.11, 95% CI 0.70 to 1.75, P = 0.65, I2=37%).
Conclusions
On meta-analysis, EVT with bridging IVT results in superior 90-day functional outcomes
and lower 90-day mortality without increase in symptomatic ICH. These findings likely
deserve further validation in a randomized controlled setting.
Keywords
Abbreviations:
AIS (Acute Ischemic Stroke), LVO (Large Vessel Occlusion), TICI (Treatment in Cerebral Ischemia), mRS (Modified Rankin Score)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Stroke and Cerebrovascular DiseasesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Outcomes and long-term mortality after basilar artery occlusion-A cohort with up to 20 years’ follow-up.Eur. J. Neurol. 2021; 28: 816-822
- Basilar artery occlusion.Lancet Neurol. 2011; 10: 1002-1014
- Recanalization of acute basilar artery occlusion improves outcomes: a meta-analysis.J. Neurointerv. Surg. 2015; 7: 868-874
- Guidelines for the early management of patients with Acute Ischemic Stroke: 2019 update to the 2018 guidelines for the early management of Acute Ischemic Stroke: A guideline for healthcare professionals from the American Heart Association/American stroke association.Stroke. 2019; 50: e344-e418
- Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.N. Engl. J. Med. 2018; 378: 11-21
- Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: The SKIP randomized clinical trial.JAMA. 2021; 325: 244-253
- Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial.Lancet Neurol. 2020; 19: 115-122
- Endovascular therapy for stroke due to basilar-artery occlusion.N. Engl. J. Med. 2021; 384: 1910-1920
- Endovascular therapy for stroke due to basilar artery occlusion: A BASIC challenge at BEST.Stroke. 2021; 52: 3410-3413
- To tPA or not to tPA, that is the question.AJNR Am. J. Neuroradiol. 2017; 38: 1464-1466
- Endovascular thrombectomy with or without intravenous alteplase in acute stroke.N. Engl. J. Med. 2020; 382: 1981-1993
- MR CLEAN-NO IV: intravenous treatment followed by endovascular treatment versus direct endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion-study protocol for a randomized clinical trial.Trials. 2021; 22: 141
- Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke: The DEVT randomized clinical trial.JAMA. 2021; 325: 234-243
- Assessing risk of bias in included studies.Cochrane Handbook for Systematic Reviews of Interventions. John Wiley & Sons, Ltd, 2008: 187-241
- Bridging versus direct endovascular therapy in basilar artery occlusion.J. Neurol. Neurosurg. Psychiatry. 2021; 92: 956-962
- Endovascular treatment with or without intravenous alteplase for acute ischaemic stroke due to basilar artery occlusion.Stroke Vasc. Neurol. 2021; (svn-2021-001242)
- Bridging thrombolysis versus direct mechanical thrombectomy in stroke due to basilar artery occlusion.J. Stroke. 2022; 24: 128-137
- Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action.Stroke. 2010; 41: 2254-2258
- Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions.Stroke. 2018; 49: 232-235
- Impact of intravenous thrombolysis on recanalization rates in patients with stroke treated with bridging therapy.Eur. J. Neurol. 2017; 24: 1016-1021
- Direct mechanical thrombectomy versus combined intravenous and mechanical thrombectomy in large-artery anterior circulation stroke: A topical review.Stroke. 2017; 48: 2912-2918
- Clot migration is associated with intravenous thrombolysis in the setting of acute ischemic stroke.Stroke. 2018; 49: 3060-3062
- Mechanical thrombectomy with and without intravenous tissue plasminogen activator for acute ischemic stroke: A systematic review and meta-analysis using Nested Knowledge.Front. Neurol. 2021; 12759759
- 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2015; 46: 3020-3035
- Alteplase reduces downstream microvascular thrombosis and improves the benefit of large artery recanalization in stroke.Stroke. 2015; 46: 3241-3248
- Tissue-type plasminogen activator is a neuroprotectant in the central nervous system.Front. Cell. Neurosci. 2015; 9: 304
- A meta-analysis of combined aspiration catheter and Stent retriever versus Stent retriever alone for large-vessel occlusion ischemic stroke.AJNR Am. J. Neuroradiol. 2022; https://doi.org/10.3174/ajnr.A7459
- Outcomes of Stent retriever versus aspiration-first thrombectomy in ischemic stroke: A systematic review and meta-analysis.AJNR Am. J. Neuroradiol. 2018; 39: 2070-2076
- Aspiration versus Stent retriever thrombectomy for posterior circulation stroke.Stroke. 2022; 53: 749-757
Article info
Publication history
Published online: October 28, 2022
Accepted:
October 18,
2022
Received in revised form:
October 16,
2022
Received:
June 21,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106847
Copyright
© 2022 Elsevier Inc. All rights reserved.
