Endovascular Thrombectomy Alone Versus Intravenous Thrombolysis Plus Thrombectomy on Acute Basilar Artery Occlusion

Study Overview
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Brief Summary
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To assess the effect of endovascular thrombectomy alone compared to intravenous thrombolysis plus endovascular thrombectomy in acute basilar artery occlusion patients within 4.5 hours from onset on efficacy and safety outcomes.

Detailed Description
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Two recent randomized, controlled trials from China-ATTENTION (Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion) and BAOCHE (Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion) have shown a significantly beneficial effect of endovascular thrombectomy in patients with an acute symptomatic basilar artery occlusion. The DEVT (Direct Endovascular Treatment versus Standard Bridging Therapy for Acute Stroke Patients with Large Vessel Occlusion in The Anterior Circulation) and DIRECT-MT (Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals Trial) trials showed that endovascular thrombectomy alone is not inferior to intravenous alteplase bridging with endovascular treatment in terms of achieving 90-day functional independence for stroke patients with large vessel occlusion. However, it is unclear whether endovascular thrombectomy alone is noninferior to intravenous thrombolysis bridging with endovascular thrombectomy for achieving functional independence at 90 days among patients with acute basilar artery occlusion. Therefore, additional studies are needed to explore the potential benefit of endovascular thrombectomy alone in these patients.

Official Title
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Endovascular Thrombectomy Alone Versus Intravenous Thrombolysis Plus Endovascular Thrombectomy on Acute Basilar Artery Occlusion - a Multicenter, Randomized Controlled, Clinical Trial

Conditions
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Basilar Artery Occlusion, Acute Cerebrovascular Accident, Stroke Due to Basilar Artery Occlusion

Intervention / Treatment
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* Drug: Intravenous thrombolysis
* Procedure: Endovascular thrombectomy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients presenting with posterior circulation ischemic stroke symptoms due to basilar artery occlusion or vertebral artery occlusions that prevent antegrade flow into the basilar artery; Time from stroke onset to randomization within 4.5 hours of estimated time of basilar artery occlusion; Patient's age ≥ 18 years; Presence of basilar artery or vertebral artery occlusion, confirmed by CT Angiography (CTA), MR Angiography (MRA) or Digital Subtraction Angiography (DSA). In case of vertebral artery occlusion, the occlusion must completely prevent antegrade flow into the basilar artery; Patients presenting with acute ischemic stroke eligible to receive both endovascular thrombectomy and intravenous thrombolysis using standard criteria; Baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 10; The patient or patient's legal representative signs the informed consent form. Exclusion Criteria: CT or MR evidence of intracerebral hemorrhage (the presence of < 10 microbleeds is allowed); Pre-stroke modified Rankin scale (mRS) score ≥ 2; Posterior circulation Acute Stroke Prognosis Early CT Score (PC-ASPECTS) on CT/ CTA-Source Images<6; PC-ASPECTS on magnetic resonance imaging-diffusion weighted imaging (MRI-DWI) <5; Pregnant or lactating women; Allergy to contrast agent or nitinol alloy; Life expectancy<1 year; CTA/MRA/DSA show vascular tortuosity, anatomical variation or artery dissection, which would make it difficult to perform endovascular treatment; Participating in other clinical trials; Systolic blood pressure >185 mmHg or diastolic blood pressure >110 mmHg, which can not be controlled by antihypertensive drugs; Genetic or acquired hemorrhagic diathesis, lack of anticoagulant factor; oral anticoagulant with international normalized ratio (INR) > 1.7; or novel oral anticoagulant within prior 48 hours; Blood glucose <50 mg/dl (2.8 mmol/L) or >400 mg/dl (22.2 mmol/L), platelet< 100*109/L; Renal insufficiency defined as serum creatinine >2.0 mg/dl (or 176.8 μ mol/l), glomerular filtration rate <30 mL/min, need for hemodialysis or peritoneal dialysis; Patients who cannot complete 90-day follow-up (such as patients without fixed residence, overseas patients, etc); The patient has acute ischemic cerebral infarction within 3 months from randomization; The patient had a history of or clinical suspicion for cerebral vasculitis or infectious endocarditis; The patient has nervous system disease or mental disorder before stroke onset, which may affect the assessment of their condition; CT or MR examination showed large cerebellar infarction with obvious space occupying effect and compression of the fourth ventricle; Patients with extensive bilateral thalamic or extensive bilateral brainstem infarction on CT or MR examination; CTA/MRA/DSA show both anterior and posterior circulation large vessel occlusion; Patients with intracranial tumors (except small meningiomas); Patients who received intravenous thrombolytics treatment before the randomization.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Endovascular thrombectomy alone<br>Patients will receive endovascular thrombectomy without intravenous thrombolysis. | Procedure: Endovascular thrombectomy<br>* Endovascular thrombectomy<br>|
| Active Comparator: Intravenous thrombolysis plus endovascular thrombectomy<br>Patients will receive intravenous alteplase (0.9mg/kg, maximum 90mg) or tenecteplase (0.25mg/kg, maximum 25mg) before endovascular thrombectomy. | Drug: Intravenous thrombolysis<br>* Patients will receive intravenous alteplase (0.9mg/kg, maximum 90mg) or tenecteplase (0.25mg/kg, maximum 25mg) before endovascular thrombectomy.<br>* Other names: Alteplase or Tenecteplase;Procedure: Endovascular thrombectomy<br>* Endovascular thrombectomy<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients with modified Rankin Score 0-2 at day 90 (±14 days) | The modified Rankin Score is an ordinal hierarchical scale ranging from 0 to 6, with higher scores indicating more severe disability. | 90 (± 14 days) after procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients with modified Rankin Score 0-3 at day 90 (±14 days) | The modified Rankin Score is an ordinal hierarchical scale ranging from 0 to 6, with higher scores indicating more severe disability. | 90 (± 14 days) after procedure | 
| Proportion of patients with modified Rankin Score 0-1 at day 90 (±14 days) | The modified Rankin Score is an ordinal hierarchical scale ranging from 0 to 6, with higher scores indicating more severe disability. | 90 (± 14 days) after procedure | 
| Proportion of patients with modified Rankin Score 0-4 at day 90 (±14 days) | The modified Rankin Score is an ordinal hierarchical scale ranging from 0 to 6, with higher scores indicating more severe disability. | 90 (± 14 days) after procedure | 
| Ordinal Shift analysis of modified Rankin Score at day 90 (±14 days) | The modified Rankin Score is an ordinal hierarchical scale ranging from 0 to 6, with higher scores indicating more severe disability. | 90 (± 14 days) after procedure | 
| Score on the National Institute of Health Stroke Scale (NIHSS) at 24 hours | The NIHSS is an ordinal hierarchical scale to evaluate the severity of stroke by assessing a patient's performance. Scores range from 0 to 42, with higher scores indicating a more severe deficit. | 24 hours after procedure | 
| Score on the NIHSS at 5-7 days or discharge | The NIHSS is an ordinal hierarchical scale to evaluate the severity of stroke by assessing a patient's performance. Scores range from 0 to 42, with higher scores indicating a more severe deficit. | 5-7 days or discharge after procedure | 
| Score on the EuroQoL 5-dimensions 5-level (EQ5D-5L) at 90 days (±14 days) | The EQ-5D-5L is a questionnaire designed to assess five dimensions of life quality related to mobility, self-care, usual activities, pain or discomfort, and anxiety or depression (range: 0.39 to 1, with a higher score indicating a higher quality of living) | 90 (± 14 days) after procedure | 
| level of activities of daily living (Barthel index, BI) at 90 days (±14 days) | The Barthel Index is an ordinal scale for measuring performance of patients'self-care activities of daily living. Scores range from 0 to 100, with 0 indicating severe disability and 95 or 100 indicating no disability that interferes with daily activities. | 90 (± 14 days) after procedure | 
| Successful reperfusion (Extended thrombolysis in cerebral infarction [eTICI] score 2b50-3) on digital substraction angiography (DSA) prior to thrombectomy | Evaluate effect of intravenous thrombolysis on reperfusion | within 5 minutes at angiography | 
| Successful reperfusion on final angiography of thrombectomy | Evaluate effect of thrombectomy on reperfusion | Within 5 minutes at final angiography of thrombectomy | 
| Successful recanalization on CT or MR angiography within 72 hours | Evaluate vascular patency after treatment | Within 72 hours after procedure | 
| Infarct volume (Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Score, PC-ASPECTS) evaluated on CT or MRI within 72 hours | PC-ASPECTS=10 indicates a normal scan, PC-ASPECTS=0 indicates early ischemic changes or hypoattenuation in all above territories. 1 or 2 points each are subtracted for early ischemic changes or hypoattenuation in: left or right thalamus, cerebellum or posterior cerebral artery territory, respectively (1 point); any part of midbrain or pons (2 points) | Within 72 hours after procedure | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Thrombectomy, thrombolysis