Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke
Authors: Chalos Vicky , LeCouffe Natalie E. , Uyttenboogaart Maarten , Lingsma Hester F. , Mulder Maxim J. H. L. , Venema Esmee , Treurniet Kilian M. , Eshghi Omid , van der Worp H. Bart , van der Lugt Aad , Roos Yvo B. W. E. M. , Majoie Charles B. L. M. , Dippel Diederik W. J. , Roozenbeek Bob , Coutinho Jonathan M. , van Oostenbrugge Robert J. , van Zwam Wim H. , Boiten Jelis , Vos Jan Albert , Jansen Ivo G. H. , Goldhoorn Robert‐Jan B. , Schonewille Wouter J. , Wermer Marieke J. H. , van Walderveen Marianne A. A. , Staals Julie , Hofmeijer Jeannette , Martens Jasper M. , Lycklama à Nijeholt Geert J. , Emmer Bart J. , de Bruijn Sebastiaan F. , van Dijk Lukas C. , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Kort Paul L. M. , Peluso Jo J. P. , van den Berg Jan S. P. , van Hasselt Boudewijn A. A. M. , Aerden Leo A. M. , Dallinga René J. , Schreuder Tobien H. C. M. L. , Heijboer Roel J. J. , Keizer Koos , Yo Lonneke S. F. , den Hertog Heleen M. , Sturm Emiel J. C. , Sprengers Marieke E. S. , Jenniskens Sjoerd F. M. , van den Berg René , Yoo Albert J. , Beenen Ludo F. M. , Roosendaal Stefan D. , van der Kallen Bas F. W. , van den Wijngaard Ido R. , van Es Adriaan C. G. M. , Bot Joseph C. J. , van Doormaal Pieter‐Jan , Flach H. Zwenneke , el Ghannouti Naziha , Sterrenberg Martin , Puppels Corina , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , van Rijswijk Cathelijn , Messchendorp Gert , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert M. , Jeurrissen D. , Bos Ernas , Drabbe Yvonne , Zweedijk Berber , Khalilzada Mostafa , Compagne Kars C. J. , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R. M. , de Jong Anouk , Hinsenveld Wouter , Berkhemer Olvert A. , Boers Anna M. M. , Groot P. F. C. , Mens Marieke A. , van Kranendonk Katinka R. , Kappelhof Manon , Tolhuijsen Manon L. , Alves Heitor 
Published: May 2019

Background

It is unclear whether intravenous thrombolysis (
IVT
) with alteplase before endovascular treatment (
EVT
) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both
IVT
and
EVT
and those treated with
EVT
alone in routine clinical practice.

Methods and Results

Using multivariable regression, we evaluated the association of
IVT
+
EVT
with 90‐day functional outcome (modified Rankin Scale), mortality, reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage in the
MR CLEAN
(Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with
IVT
+
EVT
, and 324 (22%) with
EVT
alone. Patients treated with
IVT
+
EVT
had atrial fibrillation less often (16% versus 44%) and had better pre‐stroke modified Rankin Scale scores (pre‐stroke modified Rankin Scale 0: 73% versus 52%) than those treated with
EVT
alone. Procedure time was shorter in the
IVT
+
EVT
group (median 62 versus 68 minutes). Nontransferred
IVT
+
EVT
patients had longer door‐to‐groin‐puncture times (median 105 versus 94 minutes).
IVT
+
EVT
was associated with better functional outcome (adjusted common odds ratio 1.47; 95%
CI
: 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95%
CI
: 0.40–0.82). Successful reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage did not differ between groups.

Conclusions

In this observational study, patients treated with
IVT
+
EVT
had better clinical outcomes than patients who received
EVT
alone. This finding may demonstrate a true benefit of
IVT
before
EVT
, but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of
IVT
before
EVT
.