Skip to main content

Advertisement

SpringerLink
Log in

Efficacy and safety of endovascular treatment with or without intravenous alteplase in acute anterior circulation large vessel occlusion stroke: a meta-analysis of randomized controlled trials

  • Review Article
  • Published:
Neurological Sciences Aims and scope Submit manuscript

Abstract

Objective

The current meta-analysis aimed to investigate the efficacy and safety of direct endovascular treatment (EVT) and bridging therapy (EVT with prior intravenous thrombolysis (IVT)) in patients with acute anterior circulation large vessel occlusion (LVO) stroke.

Methods

This meta-analysis followed PRISMA guidelines. Eligible RCTs were identified through a systemic search of electronic databases (PubMed, Ovid, Web of Science, and Cochrane Library) from the inception dates to January 10, 2022. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) at 90 days. The secondary outcomes included successful reperfusion, intracranial hemorrhage, and mortality (mRS 6) within 90 days.

Results

A total of 4 RCTs involving 1633 patients were finally included. Findings of pooled analyses indicated that neither the primary outcomes (no disability (mRS 0), no significant disability despite some symptoms (mRS 1), slight disability (mRS 2), moderate disability (mRS 3), moderately severe disability (mRS 4), severe disability (mRS 5), excellent outcome (mRS 0–1), functional independence outcome (mRS 0–2), and poor outcome (mRS 3–5)) nor the secondary outcomes (successful reperfusion, intracranial hemorrhage, and mortality) in the EVT groups were not statistically significant compared with the IVT plus EVT groups (P > 0.05). In addition, the outcomes of sensitivity analysis implied that the findings of meta-analysis were credible.

Conclusions

Among patients with acute ischemic stroke due to LVO of anterior circulation, EVT alone yielded efficacy and safety outcomes similar to IVT plus EVT.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11

Similar content being viewed by others

References

  1. Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20

    Article  PubMed  CAS  Google Scholar 

  2. Goyal M, Demchuk AM, Menon BK et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030

    Article  CAS  PubMed  Google Scholar 

  3. Campbell BC, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018

    Article  CAS  PubMed  Google Scholar 

  4. Jovin TG, Chamorro A, Cobo E et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306

    Article  CAS  PubMed  Google Scholar 

  5. Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs t-PA alone in stroke. N Engl J Med 372:2285–95

    Article  CAS  PubMed  Google Scholar 

  6. Bracard S, Ducrocq X, Mas JL et al (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet neurol 15:1138–1147

    Article  CAS  PubMed  Google Scholar 

  7. Abilleira S, Ribera A, Cardona P et al (2017) Outcomes after direct thrombectomy or combined intravenous and endovascular treatment are not different. Stroke 48:375–378

    Article  PubMed  Google Scholar 

  8. Coutinho JM, Liebeskind DS, Slater LA et al (2017) Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the SWIFT and STAR studies. JAMA Neurol 74:268–274

    Article  PubMed  Google Scholar 

  9. Bellwald S, Weber R, Dobrocky T et al (2017) Direct mechanical intervention versus bridging therapy in stroke patients eligible for intravenous thrombolysis: a pooled analysis of 2 registries. Stroke 48:3282–3288

    Article  PubMed  Google Scholar 

  10. Kaesmacher J, Mordasini P, Arnold M et al (2019) Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis. J Neurointerv Surg 11:20–27

    Article  PubMed  Google Scholar 

  11. Gariel F, Lapergue B, Bourcier R et al (2018) Mechanical thrombectomy outcomes with or without intravenous thrombolysis. Stroke 49:2383–2390

    Article  PubMed  Google Scholar 

  12. Chalos V, LeCouffe NE, Uyttenboogaart M et al (2019) Endovascular treatment with or without prior intravenous alteplase for acute ischemic stroke. J Am Heart Assoc 8:e11592

    Article  Google Scholar 

  13. Katsanos AH, Malhotra K, Goyal N et al (2019) Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions. Ann Neurol 86:395–406

    Article  PubMed  Google Scholar 

  14. Mistry EA, Mistry AM, Nakawah MO et al (2017) Mechanical thrombectomy outcomes with and without intravenous thrombolysis in stroke patients: a meta-analysis. Stroke 48:2450–2456

    Article  PubMed  Google Scholar 

  15. Trifan G, Biller J, Testai FD (2022) Mechanical Thrombectomy vs bridging therapy for anterior circulation large vessel occlusion stroke: systematic review and meta-analysis. Neurology

  16. Wang Y, Wu X, Zhu C et al (2021) Bridging thrombolysis achieved better outcomes than direct thrombectomy after large vessel occlusion: an updated meta-analysis. Stroke 52:356–365

    Article  PubMed  Google Scholar 

  17. Tsivgoulis G, Katsanos AH, Schellinger PD et al (2018) Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions. Stroke 49:232–235

    Article  PubMed  Google Scholar 

  18. Behme D, Kabbasch C, Kowoll A et al (2016) Intravenous thrombolysis facilitates successful recanalization with stent-retriever mechanical thrombectomy in middle cerebral artery occlusions. J Stroke Cerebrovasc Dis 25:954–959

    Article  PubMed  Google Scholar 

  19. Desilles JP, Loyau S, Syvannarath V et al (2015) Alteplase reduces downstream microvascular thrombosis and improves the benefit of large artery recanalization in stroke. Stroke 46:3241–3248

    Article  PubMed  Google Scholar 

  20. Grotta JC, Hacke W (2015) Stroke Neurologist’s perspective on the new endovascular trials. Stroke 46:1447–1452

    Article  PubMed  Google Scholar 

  21. Ren Y, Churilov L, Mitchell P et al (2018) Clot migration is associated with intravenous thrombolysis in the setting of acute ischemic stroke. Stroke 49:3060–3062

    Article  PubMed  Google Scholar 

  22. Yaghi S, Eisenberger A, Willey JZ (2014) Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA Neurol 71:1181–1185

    Article  PubMed  PubMed Central  Google Scholar 

  23. Alves HC, Treurniet KM, Jansen I et al (2019) Thrombus migration paradox in patients with acute ischemic stroke. Stroke 50:3156–3163

    Article  PubMed  PubMed Central  Google Scholar 

  24. Page MJ, McKenzie JE, Bossuyt PM, et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ n71

  25. Higgins JPT, Altman DG, Gotzsche PC et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  PubMed  PubMed Central  Google Scholar 

  26. Yang P, Zhang Y, Zhang L et al (2020) Endovascular Thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med 382:1981–1993

    Article  CAS  PubMed  Google Scholar 

  27. Zi W, Qiu Z, Li F et al (2021) Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke. JAMA 325:234

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Suzuki K, Matsumaru Y, Takeuchi M et al (2021) Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke. JAMA 325:244

    Article  PubMed  PubMed Central  Google Scholar 

  29. LeCouffe NE, Kappelhof M, Treurniet KM et al (2021) A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med 385:1833–1844

    Article  CAS  PubMed  Google Scholar 

  30. Katsanos AH, Tsivgoulis G (2019) Is intravenous thrombolysis still necessary in patients who undergo mechanical thrombectomy? Curr Opin Neurol 32:3–12

    Article  PubMed  Google Scholar 

  31. Broeg-Morvay A, Mordasini P, Bernasconi C et al (2016) Direct mechanical intervention versus combined intravenous and mechanical intervention in large artery anterior circulation stroke: a matched-pairs analysis. Stroke 47:1037–1044

    Article  PubMed  Google Scholar 

  32. Weber R, Nordmeyer H, Hadisurya J et al (2017) Comparison of outcome and interventional complication rate in patients with acute stroke treated with mechanical thrombectomy with and without bridging thrombolysis. J Neurointerv Surg 9:229–233

    Article  PubMed  Google Scholar 

  33. Wang H, Zi W, Hao Y et al (2017) Direct endovascular treatment: an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke. Eur J Neurol 24:935–943

    Article  CAS  PubMed  Google Scholar 

  34. Bellwald S, Weber R, Dobrocky T et al (2017) Direct mechanical intervention versus bridging therapy in stroke patients eligible for intravenous thrombolysis: a pooled analysis of 2 registries. Stroke 48:3282–3288

    Article  PubMed  Google Scholar 

  35. Gong L, Zheng X, Feng L et al (2019) Bridging therapy versus direct mechanical thrombectomy in patients with acute ischemic stroke due to middle cerebral artery occlusion: a clinical- histological analysis of retrieved thrombi. Cell Transplant 28:684–690

    Article  PubMed  PubMed Central  Google Scholar 

  36. Tong X, Wang Y, Fiehler J et al (2021) Thrombectomy versus combined thrombolysis and thrombectomy in patients with acute stroke: a matched-control study. Stroke 52:1589–1600

    Article  PubMed  Google Scholar 

  37. Pienimaki JP, Ollikainen J, Sillanpaa N et al (2021) In-hospital intravenous thrombolysis offers no benefit in mechanical thrombectomy in optimized tertiary stroke center setting. Cardiovasc Intervent Radiol 44:580–586

    Article  PubMed  Google Scholar 

  38. Du M, Li S, Huang X et al (2021) Intravenous thrombolysis before thrombectomy may increase the incidence of intracranial hemorrhage in treating carotid T occlusion. J Stroke Cerebrovasc Dis 30:105473

    Article  PubMed  Google Scholar 

  39. Phan K, Dmytriw AA, Lloyd D et al (2019) Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis. J Neurointerv Surg 11:443–449

    Article  PubMed  Google Scholar 

  40. Zhang J, Chen S, Shi S, et al (2021) Direct endovascular treatment versus bridging therapy in patients with acute ischemic stroke eligible for intravenous thrombolysis: systematic review and meta-analysis. J Neurointerv Surg

  41. Mokin M, Waqas M, Fifi JT, et al (2021) Intravenous alteplase has different effects on the efficacy of aspiration and stent retriever thrombectomy: analysis of the COMPASS trial. J Neurointerv Surg

  42. Anderson CS, Robinson T, Lindley RI et al (2016) Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. N Engl J Med 374:2313–2323

    Article  CAS  PubMed  Google Scholar 

  43. Seners P, Turc G, Maier B et al (2016) Incidence and predictors of early recanalization after intravenous thrombolysis: a systematic review and meta-analysis. Stroke 47:2409–2412

    Article  CAS  PubMed  Google Scholar 

  44. Feldmann E, Daneault N, Kwan E et al (1990) Chinese-white differences in the distribution of occlusive cerebrovascular disease. Neurology 40:1541–1545

    Article  CAS  PubMed  Google Scholar 

  45. Molina CA, Montaner J, Arenillas JF et al (2004) Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes. Stroke 35:486–490

    Article  PubMed  Google Scholar 

  46. Lin CJ, Saver JL (2019) Noninferiority margins in trials of thrombectomy devices for acute ischemic stroke: is the bar being set too low? Stroke 50:3519–3526

    Article  PubMed  Google Scholar 

  47. Lin CH, Saver JL, Ovbiagele B et al (2022) Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials. J Neurointerv Surg 14:227–232

    Article  PubMed  Google Scholar 

  48. Menon BK, Al-Ajlan FS, Najm M et al (2018) Association of clinical, imaging, and thrombus characteristics with recanalization of visible intracranial occlusion in patients with acute ischemic stroke. JAMA 320:1017–1026

    Article  PubMed  PubMed Central  Google Scholar 

  49. Kaesmacher J, Maamari B, Meinel TR et al (2020) Effect of pre- and in-hospital delay on reperfusion in acute ischemic stroke mechanical thrombectomy. Stroke 51:2934–2942

    Article  PubMed  PubMed Central  Google Scholar 

  50. Campbell B, Mitchell PJ, Churilov L et al (2018) Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med 378:1573–1582

    Article  CAS  PubMed  Google Scholar 

  51. Deeds SI, Barreto A, Elm J et al (2021) The multiarm optimization of stroke thrombolysis phase 3 acute stroke randomized clinical trial: rationale and methods. Int J Stroke 16:873–880

    Article  PubMed  Google Scholar 

  52. Mueller L, Pult F, Meisterernst J et al (2017) Impact of intravenous thrombolysis on recanalization rates in patients with stroke treated with bridging therapy. Eur J Neurol 24:1016–1021

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We thank “Neurological Sciences” for providing such an excellent academic exchange platform.

Funding

The funding was provided by the National Natural Science Foundation of China (NSFC Grants 81701206).

Author information

Author notes

  1. Jun Zhang and Cong Yuan contributed equally to this work.

Authors and Affiliations

  1. Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Urumqi Middle Road, Jing’an District, Shanghai, 200040, China

    Jun Zhang, Cong Yuan, Xinyu Deng, Qiang Yuan, Meihua Wang, Pengfei Fu, Jiang Fang, Zhuoying Du & Jin Hu

  2. Neurosurgical Institute of Fudan University, Shanghai, 200040, China

    Jun Zhang, Cong Yuan, Xinyu Deng, Qiang Yuan, Meihua Wang, Pengfei Fu, Jiang Fang, Zhuoying Du & Jin Hu

  3. Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China

    Jun Zhang, Cong Yuan, Xinyu Deng, Qiang Yuan, Meihua Wang, Pengfei Fu, Jiang Fang, Zhuoying Du & Jin Hu

  4. Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China

    Jun Zhang, Cong Yuan, Xinyu Deng, Qiang Yuan, Meihua Wang, Pengfei Fu, Jiang Fang, Zhuoying Du & Jin Hu

Authors
  1. Jun Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Cong Yuan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xinyu Deng
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Qiang Yuan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Meihua Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Pengfei Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jiang Fang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Zhuoying Du
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jin Hu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Zhuoying Du or Jin Hu.

Ethics declarations

Ethical approval.

N/A.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, J., Yuan, C., Deng, X. et al. Efficacy and safety of endovascular treatment with or without intravenous alteplase in acute anterior circulation large vessel occlusion stroke: a meta-analysis of randomized controlled trials. Neurol Sci 43, 3551–3563 (2022). https://doi.org/10.1007/s10072-022-06017-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10072-022-06017-8

Keywords

Search

Navigation