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Combining thrombectomy with alteplase has tradeoffs

Journal
JAMA Neurology
Reuters Health - 17/06/2022 - For acute ischemic stroke due to large-vessel occlusion, combining endovascular thrombectomy (EVT) with alteplase leads to improved survival and less disability, but higher risk of symptomatic intracranial hemorrhage, new research suggests.

The effectiveness and safety of intravenous alteplase given before or concurrently with EVT remains uncertain.

Data from randomized clinical trials suggest there is "little difference in outcomes but with only modest precision and insufficient power to analyze uncommon outcomes including symptomatic intracranial hemorrhage," the study team points out in JAMA Neurology.

To investigate further, Dr. Eric Smith with the Calgary Stroke Program in Canada and colleagues compared outcomes of 15,832 patients treated with EVT either with or without alteplase in the Get With The Guidelines-Stroke (GWTG-Stroke) registry.

Patients treated with alteplase were younger, arrived via emergency medical services sooner, were less likely to have certain comorbid conditions, including atrial fibrillation, hypertension, and diabetes, but had similar stroke severity.

Compared with patients who did not receive alteplase, those who did get alteplase were less likely to die (adjusted odds ratio, 0.83; P<0.001) and more likely to have no major disability at discharge (aOR, 1.36; P<0.001) and to have better reperfusion (aOR, 1.39; P<0.001).

However, those given alteplase had a higher risk of symptomatic brain bleeds (OR, 1.28; P<0.001).

These findings support current European recommendations that alteplase should continue to be used in eligible patients undergoing EVT, the researchers say.

"Although alteplase treatment probably increases the risk of symptomatic intracranial hemorrhage after EVT in routine clinical practice, this does not translate to worsening in discharge disability or mortality. Alteplase or other thrombolytics may still have an important role in patients undergoing EVT for large vessel occlusion, particularly in patients where a delay in accessing the angiography suite is anticipated, such as when transfer to an EVT-capable site is required or when personnel are off-site," they add.

To fully define the role of alteplase or other lytics (eg, tenecteplase) in combination with EVT, more data from randomized clinical trials will be needed to narrow the margin of noninferiority or to prove superiority," they note.

The Get With The Guidelines-Stroke program is sponsored, in part, by Novartis, Boehringer Ingelheim and Eli Lilly Diabetes Alliance, Novo Nordisk, Sanofi, AstraZeneca, Bayer, Tylenol and Alexion Pharmaceuticals.

SOURCE: https://bit.ly/3NXzm7G JAMA Neurology, online June 13, 2022.

By Reuters Staff



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