Acute Stroke treatment

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Q: Should we skip IV-Alteplase for acute ischemic stroke (AIS) patients with large vessel occlusion (LVO)?

 

A: No we should not. 

 

DIRECT-MT trial showed that in Chinese patients with AIS from LVO, endovascular treatment alone was noninferior to endovascular treatment with IV-Alteplase with regard to functional outcome. According to an editorial paper Dr. Albers wrote, “However, the margin that was used to declare noninferiority was generous, and the conference intervals did not exclude a benefit of approximately 20% in the combined treatment group.”

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The only difference between these two groups was that the combined treatment group had more successful reperfusion before thrombectomy 7% Vs 2.4%, OR: 0.33 (0.14-0.74). Only 23/319 of patients in the combined Rx group finished tPA prior starting the endovascular procedure. This might obscure the effect of IV-Alteplase. Giving IV-Alteplase can recanalize occlusion completely prior to endovascular Rx and it can help dissolving the fragmented thrombi during mechanical thrombectomy. 

 

The mortality and symptomatic ICH were not different in both groups. At the end, the authors and editor recommend to continue giving IV-Alteplase for AIS with LVO patients. They recommend larger RCT studies in the different population.

Reference:

 

Albers GW. Thrombolysis before Thrombectomy - To Be or DIRECT-MT? [published online ahead of print, 2020 May 6]. N Engl J Med. 2020;10.1056/NEJMe2004550. doi:10.1056/NEJMe2004550.

 

Yang P, Zhang Y, Zhang L, et al. Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke [published online ahead of print, 2020 May 6]. N Engl J Med. 2020;10.1056/NEJMoa2001123. doi:10.1056/NEJMoa2001123