Outcomes in Endovascular Thrombectomy Similar With or Without Alteplase

March 24, 2021
By Nancy Melville YORK, Me -- March 23, 2021 -- Outcomes in the treatment of acute ischaemic stroke with endovascular thrombectomy appear similar with or without prior use of intravenous (IV) thrombolysis with alteplase, according to a study presented at the 2021 Virtual International Stroke Conference (ISC). “We did not show superiority or noninferiority of direct endovascular treatment over IV alteplase followed by endovascular treatment,” said Yvo Roos, MD, Amsterdam UMC, Amsterdam, the Netherlands. Although alteplase may provide benefit even when mechanical treatment is not entirely successful, the medication has some drawbacks, including increased risk of bleeding and added cost, Dr. Roos noted. Furthermore, the recent DIRECT-MT trial of 656 patients found significant noninferiority of direct endovascular therapy (without alteplase) in terms of functional outcomes, with fewer haemorrhages, albeit nonsignificant, with the direct approach. The MR CLEAN-NO IV trial included 539 patients with acute ischaemic stroke with acute ischaemic stroke involving a large clot in the anterior circulation. Patients were randomised to treatment with direct endovascular thrombectomy plus IV alteplase 0.9 mg/kg (n = 266) or without the medication (n = 273). For the primary outcome of ordinal modified Rankin scale score, after adjustment for age, baseline National Institutes of Health Stroke Scale (NIHSS), collateral score, prestroke functioning, and onset-randomisation time, the outcomes between the 2 groups were similar after 90 days, with an adjusted odds ratio (aOR) of 0.88 (95% confidence interval [CI], 0.65-1.19), which was not statistically significant. Among patients with direct endovascular treatment, 49.1% were able to live independently after their stroke, compared with 51.1% of patients in the alteplase group. No significant differences were observed in functional outcomes between the groups. The rates of treatment success were 78.3% and 83.1%, respectively, (aOR, = 0.72; 95% CI, 0.45-1.13). No significant differences were found in rates of symptomatic brain haemorrhage, which were 5.9% for the patients who did not receive alteplase compared with 5.3% for patients who did (aOR = 1.31; 95% CI, 0.61-2.84). The mortality rate was 20.5% in the direct endovascular treatment group versus 15.8% in the alteplase group (aOR = 1.39; 95% CI, 0.84-2.30). “The MR CLEAN-NO IV trial did not show a clear difference in outcomes for administering or forgoing intravenous alteplase before mechanical treatment for patients with acute ischaemic stroke directly admitted to thrombectomy-capable centres, which is consistent with the results of 3 previous trials,” said Dr. Roos. “We furthermore found similar haemorrhage rates with or without IV alteplase administration before endovascular treatment.” ISC is sponsored by the American Heart Association and the American Stroke Association. [Presentation title: Intravenous Thrombolysis Followed by Endovascular Thrombectomy Versus Direct Endovascular Thrombectomy: A Randomized Controlled Trial. Abstract LB3]