Effect of Intravenous Alteplase Treatment on First-Line Stent Retriever Versus Aspiration Alone During Endovascular Treatment
Leon A. Rinkel, Kilian M. Treurniet, Daan Nieboer, Manon Kappelhof, Natalie E. LeCouffe, Agnetha A.E. Bruggeman, Wim H. van Zwam, Geert J. Lycklama à Nijeholt, Elyas Ghariq, Maarten Uyttenboogaart, Diederik W.J. Dippel, Yvo B.W.E.M. Roos, Jonathan M. Coutinho, Charles B.L.M. Majoie, Bart J. Emmer, Bob Roozenbeek, Adriaan van Es, Inger de Ridder, H. Bart van der Worp, Rob Lo, Koos Keizer, Rob A.R. Gons, Lonneke S.F. Yo, Jelis Boiten, Ido R. van den Wijngaard, Jeanette Hofmeijer, Jasper M. Martens, Wouter J. Schonewille, Jan Albert Vos, Anil M. Tuladhar, Floris H.B.M. Schreuder, Jeroen Boogaarts, Sjoerd F.M. Jenniskens, Karlijn de Laat, Lukas van Dijk, Heleen den Hertog, Boudewijn van Hasselt, Paul J.A.M. Brouwers, Emiel J.C. Sturm, Tomas Bulut, Michel Remmers, Anouk van Norden, Thijs de Jong, Anouk D. Rozeman, Otto E. H. Elgersma, Reinoud P.H. Bokkers, Julia van Tuijl, Issam Boukrab, Hans Kortman, Vincent Costalat, Caroline Arquizan, Robin Lemmens, Jelle Demeestere, Philippe Desfontaines, Denis Brisbois, Frédéric Clarençon, Yves Samson, Adriaan van Es, Jelis Boiten, Lonneke S.F. Yo, Koos Keizer, Martin M. Brown, Phil White, John Gregson, Rick van Nuland, Aad van der Lugt, Linda Jacobi, René van den Berg, Ludo F.M. Beenen, Adriaan van Es, Pieter‐Jan van Doormaal, Ido R. van den Wijngaard, Albert J. Yoo, Lonneke S.F. Yo, Jasper M. Martens, Bas Hammer, Stefan D. Roosendaal, Anton Meijer, Menno Krietemeijer, Reinoud P.H. Bokkers, Anouk van der Hoorn, Dick Gerrits, Robert van Oostenbrugge, Ben Jansen, Sanne Manschot, Henk Kerkhof, Ido R. van den Wijngaard, Peter J. Koudstaal, Koos Keizer, Hester F. Lingsma, Vicky Chalos, Olvert A. Berkhemer, Aad van der Lugt, Adriaan Versteeg, Lennard Wolff, Jiahang Su, Manon L. Tolhuisen, Henk van Voorst, Hugo Ten Cate, Moniek P.M. de Maat
Abstract
BACKGROUND: We aimed to assess whether the effect of intravenous alteplase treatment (IVT) before endovascular treatment (EVT) on outcome is modified by first-line technique during EVT in IVT eligible patients. METHODS: This was a post hoc analysis from MR CLEAN-NO IV (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands - Intravenous Treatment Followed by Intra-Arterial Treatment Versus Direct Intra-Arterial Treatment for Acute Ischemic Stroke Caused by a Proximal Intracranial Occlusion), a randomized trial of IVT followed by EVT versus EVT alone in patients presenting directly to EVT-capable centers. We included data from all patients who underwent EVT with a thrombectomy attempt. We compared patients treated with stent retriever (with or without aspiration) to aspiration alone as first-line EVT technique and assessed the interaction of first-line EVT technique with IVT treatment. Primary outcome was the 90-day modified Rankin Scale score, analyzed with mixed model ordinal regression for a shift towards better outcome. Secondary outcomes included successful reperfusion (extended Thrombolysis in Cerebral Infarction score 2b-3). RESULTS: =0.03). In the aspiration-only group, patients treated with EVT alone had worse functional outcome compared to those treated with IVT and EVT (acOR, 0.44 [95% CI, 0.21-0.90]). In the stent retriever group, functional outcome did not differ between patients treated with or without IVT (acOR, 1.08 [95% CI, 0.74-1.57]). There was no statistically significant interaction for successful reperfusion. CONCLUSIONS: In MR CLEAN-NO IV, the treatment effect of IVT was modified by first-line EVT technique. Patients treated with aspiration only as first-line technique had worse clinical outcomes if they did not receive IVT. No such difference was observed in patients treated with stent retrievers. Confirmation by pooling with results from other trials is needed to confirm these findings.