Endovascular Thrombectomy for Acute Ischemic Stroke in Failed Intravenous Tissue Plasminogen Activator Versus Non-Intravenous Tissue Plasminogen Activator Patients: Revascularization and Outcomes Stratified by the Site of Arterial Occlusions

• Published in: Stroke (1970) Vol. 41; no. 6; pp. 1185 - 1192
• Main Authors: SHI, Zhong-Song, LOH, Yince, WALKER, Gary, DUCKWILER, Gary R
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 01-06-2010
• Subjects: Aged; Aged, 80 and over; Biological and medical sciences; Blood. Blood coagulation. Reticuloendothelial system; Brain Ischemia - mortality; Brain Ischemia - therapy; Carotid Artery Diseases - mortality; Carotid Artery Diseases - therapy; Cerebral Arterial Diseases - mortality; Cerebral Arterial Diseases - therapy; Cerebral Revascularization - methods; Disease-Free Survival; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - adverse effects; Hemorrhage - etiology; Hemorrhage - mortality; Hemorrhage - therapy; Humans; Infusions, Intravenous; Male; Medical sciences; Middle Aged; Neurology; Pharmacology. Drug treatments; Stroke - mortality; Stroke - therapy; Survival Rate; Thrombectomy; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - adverse effects; Vascular diseases and vascular malformations of the nervous system; Prognosis; Intravenous administration; thrombectomy; Cardiovascular disease; endovascular treatment; t-Plasminogen activator; Arterial disease; Vascular disease; acute stroke; Cerebrovascular disease; outcome; Revascularization; Human; Cerebral infarction; Stroke; Nervous system diseases; Serine endopeptidases; Enzyme; Endovascular route; Cerebral disorder; Peptidases; Treatment; Central nervous system disease; Brain ischemia; thrombolysis; Hydrolases; Artery occlusion; Comparative study
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/STROKEAHA.109.568451

Intracranial mechanical thrombectomy is a therapeutic option for acute ischemic stroke patients failing intravenous tissue plasminogen activator (IV tPA). We compared patients treated by mechanical embolus removal in cerebral ischemia (MERCI) thrombectomy after failed IV tPA with those treated with thrombectomy alone.
We pooled MERCI and Multi MERCI study patients, grouped them either as failed IV tPA or non-IV tPA, and assessed revascularization rates, procedural complications, symptomatic hemorrhage rates, clinical outcomes, and mortality. We also evaluated outcomes stratified by the occlusion site and final revascularization.
Among 305 patients, 48 failed, and 257 were ineligible for IV tPA. Nonresponders to IV tPA trended toward a higher revascularization rate (73% versus 63%) and less mortality (27.7% versus 40.1%) and had similar rates of symptomatic hemorrhage and procedural complications. Favorable 90-day outcomes were similar in failed and non-IV tPA patients (38% versus 31%), with no difference according to occlusion site. Among patients failing IV tPA, good outcomes tended to occur more frequently in revascularized patients (47.1% versus 15.4%), although this relationship was attributable solely to middle cerebral artery and not internal carotid artery occlusions, with no difference in mortality. Among IV tPA-ineligible patients, revascularization correlated with good outcome (47.4% versus 4.4%) and less mortality (28.5% versus 59.6%).
The risks of hemorrhage and procedure-related complications after mechanical thrombectomy do not differ with respect to previous IV tPA administration. Thrombectomy after IV tPA achieves similar rates of good outcomes, a tendency toward lower mortality, and similar revascularization rates when stratified by clot location. Good outcomes correlate with successful revascularization except with internal carotid artery occlusions in tPA-nonresponders.