Effect of Intravenous Alteplase Treatment on First-Line Stent Retriever Versus Aspiration Alone During Endovascular Treatment
Authors: Rinkel Leon A. , Treurniet Kilian M. , Nieboer Daan , Kappelhof Manon , LeCouffe Natalie E. , Bruggeman Agnetha A.E. , van Zwam Wim H. , Lycklama à Nijeholt Geert J. , Ghariq Elyas , Uyttenboogaart Maarten , Dippel Diederik W.J. , Roos Yvo B.W.E.M. , Coutinho Jonathan M. , Majoie Charles B.L.M. , Emmer Bart J. , Roozenbeek Bob , van Es Adriaan , de Ridder Inger , van der Worp Bart , Lo Rob , Keizer Koos , Gons Rob , Yo Lonneke , Boiten Jelis , van den Wijngaard Ido , Hofmeijer Jeanette , Martens Jasper , Schonewille Wouter , Albert Vos Jan , Tuladhar Anil , Schreuder Floris , Boogaarts Jeroen , Jenniskens Sjoerd , de Laat Karlijn , van Dijk Lukas , den Hertog Heleen , van Hasselt Boudewijn , Brouwers Paul , Sturm Emiel , Bulut Tomas , Remmers Michel , van Norden Anouk , de Jong Thijs , Rozeman Anouk , Elgersma Otto , Bokkers Reinoud , van Tuijl Julia , Boukrab Issam , Kortman Hans , Costalat Vincent , Arquizan Caroline , Lemmens Robin , Demeestere Jelle , Desfontaines Philippe , Brisbois Denis , Clarençon Frédéric , Samson Yves , van Es Adriaan , Boiten Jelis , Yo Lonneke , Keizer Koos , Brown Martin , White Phil , Gregson John , van Nuland Rick , van der Lugt Aad , Jacobi Linda , van den Berg René , Beenen Ludo , van Es Adriaan , van Doormaal Pieter-Jan , van den Wijngaard Ido , Yoo Albert , Yo Lonneke , Martens Jasper , Hammer Bas , Roosendaal Stefan , Meijer Anton , Krietemeijer Menno , Bokkers Reinoud , van der Hoorn Anouk , Gerrits Dick , van Oostenbrugge Robert , Jansen Ben , Manschot Sanne , Kerkhof Henk , van den Wijngaard Ido , Koudstaal Peter , Keizer Koos , Lingsma Hester , Chalos Vicky , Berkhemer Olvert , van der Lugt Aad , Versteeg Adriaan , Wolff Lennard , Su Jiahang , Tolhuisen Manon , van Voorst Henk , ten Cate Hugo , de Maat Moniek , Donse-Donkel Samantha , van Beusekom Heleen , Taha Aladdin , Chalos Vicky , van den Berg Sophie , van de Graaf Rob , Goldhoorn Robert-Jan , Taha Aladdin , Donse-Donkel Samantha , Hinsenveld Wouter , Pirson Anne , Sondag Lotte , Reinink Rik , Tolhuisen Manon , Brouwer Josje , Wolff Lennard , Collette Sabine , van der Steen Wouter , Sprengers Rita , Sterrenberg Martin , El Ghannouti Naziha , Verheesen Sabrina , Pellikaan Wilma , Blauwendraat Kitty , Drabbe Yvonne , de Meris Joke , Simons Michelle , Bongenaar Hester , van Loon Anja , Ponjee Eva , Eilander Rieke , Kooij Suze , de Jong Marieke , Santegoets Esther , Roodenburg Suze , van Ahee Ayla , Moynier Marinette , Devroye Annemie , Marcis Evelyn , Iezzi Ingrid , David Annie , Talbi Atika , Heiligers Leontien , Martens Yvonne 
Published: July 2022

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:

Of 473 included patients, 102 (21.6%) were treated with aspiration alone as first-line technique. In the full population, functional outcome was similar for patients treated with stent retriever versus aspiration only (adjusted common odds ratio [acOR]‚ 1.07 [95% CI, 0.69–1.66]). We observed a significant interaction between IVT and first-line EVT technique (
P
=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.