No benefit to skipping alteplase before endovascular treatment

Reuters Health - 10/11/2021 - Skipping intravenous alteplase therapy before endovascular treatment (EVT) does not produce better outcomes in people with acute ischemic stroke whose large-scale occlusion makes them eligible for EVT, according to results of the MR CLEAN-NO IV trial.

"In this European trial of anterior-circulation stroke, EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with respect to functional outcomes at 90 days in patients presenting directly to centers capable of providing both treatments," Dr. Yvo Roos of Amsterdam UMC, University of Amsterdam, and colleagues write in the New England Journal of Medicine.

About a quarter of ischemic strokes are caused by an occlusion of a large vessel. Current guidelines recommend administration of alteplase before EVT in eligible patients, but this treatment has not been extensively studied, particularly in non-Asian populations, the researchers note.

They conducted an open-label, multicenter, randomized trial involving 547 stroke patients who presented directly to a hospital capable of providing EVT and who were eligible for intravenous alteplase and EVT. The patients were treated at 20 hospitals in the Netherlands, Belgium and France.

The median score on the modified Rankin scale was 2 after 90 days among those getting alteplase before EVT and 3 among patients who skipped the alteplase and a thrombectomy was attempted immediately (adjusted common odds ratio, 0.84; 95% confidence interval, 0.62 to 1.15). The margin of noninferiority for thrombectomy alone was 0.8.

Mortality was 15.8% with standard care but 20.5% with EVT alone (adjusted odds ratio, 1.39; 95% CI, 0.84 to 2.30).

When alteplase was used, 5.3% had a symptomatic intracerebral hemorrhage. The rate was 5.9% in the direct-to-EVT group.

Previous tests of the question have produced mixed results. but the strengths of the new study and "the absence of a finding of superiority of thrombectomy alone in MR CLEAN-NO IV supports not prematurely abandoning thrombolysis before thrombectomy for stroke," Dr. Alfonso Ciccone of Italy's Azienda Socio Sanitaria Territoriale of Mantova concluded in a linked editorial.

The results were originally released on March 18 at the American Stroke Association's International Stroke Conference.

SOURCES: https://bit.ly/3CSvkrF and https://bit.ly/3wr5icS The New England Journal of Medicine, online November 10, 2021.

By Reuters Staff



Posted on 10 November, 202116 November, 2021