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No space left for intravenous thrombolysis in acute stroke: PROS

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Abstract

Five recently published RCTs (MR CLEAN, EXTEND-IA, SWIFT PRIME, REVASCAT and ESCAPE) employing mechanical thrombectomy with modern stent retriever devices clearly demonstrated the superiority of endovascular treatment compared to thrombolysis alone, which is now considered standard first-line therapy for selected patients with acute severe ischemic stroke and large vessel in the anterior circulation. RCT results led to recommendations outlined in “Mechanical thrombectomy in acute ischemic stroke by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN”. Moreover, endovascular procedures in the 5 RCTs to date were performed at high-volume referral centers with, in some trials, rigid requirements for the interventionalist to participate, which may have contributed substantially to the excellent results, supporting the concept of centralization of intra-arterial thrombolysis resources and expertise. Therefore, patients with suspected large-artery occlusion and deemed candidates for thrombectomy, should be treated at a Comprehensive Stroke Centre with 24/7 endovascular treatment services. There seems to be limited space left for intravenous thrombolysis alone in acute stroke patients with large-vessel occlusions as thrombectomy plus thrombolysis continues to be reported as being superior with regard to outcome.

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References

  1. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, Silver FL, von Kummer R, Molina CA, Demaerschalk BM, Budzik R, Clark WM, Zaidat OO, Malisch TW, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Martin RH, Foster LD, Tomsick TA, Interventional Management of Stroke (IMS) III Investigators (2013) Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 368(10):893–903. doi:10.1056/NEJMoa1214300

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, Boccardi E, Expansion Investigators SYNTHESIS (2013) Endovascular treatment for acute ischemic stroke. N Engl J Med 368(10):904–913. doi:10.1056/NEJMoa1213701

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, Feng L, Meyer BC, Olson S, Schwamm LH, Yoo AJ, Marshall RS, Meyers PM, Yavagal DR, Wintermark M, Guzy J, Starkman S, Saver JL, Investigators MRRESCUE (2013) A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 368(10):914–923. doi:10.1056/NEJMoa1212793

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Goyal M, Almekhlafi M, Menon B, Hill M, Fargen K, Parsons M, Bang OY, Siddiqui A, Andersson T, Mendes V, Davalos A, Turk A, Mocco J, Campbell B, Nogueira R, Gupta R, Murphy S, Jovin T, Khatri P, Miao Z, Demchuk A, Broderick JP, Saver J (2014) Challenges of acute endovascular stroke trials. Stroke 45(10):3116–3122. doi:10.1161/STROKEAHA.114.006288

    Article  PubMed  Google Scholar 

  5. Manning NW, Campbell BC, Oxley TJ, Chapot R (2014) Acute ischemic stroke: time, penumbra, and reperfusion. Stroke 45(2):640–644. doi:10.1161/STROKEAHA.113.003798

    Article  PubMed  Google Scholar 

  6. Parsons MW, Albers GW (2013) MR RESCUE: is the glass half-full or half-empty? Stroke 44(7):2055–2057. doi:10.1161/STROKEAHA.113.001443

    Article  PubMed  Google Scholar 

  7. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM, Investigators EXTEND-IA (2015) Endovascular therapy for ischemic stroke with perfusion imaging selection. N Engl J Med 372(11):1009–1018. doi:10.1056/NEJMoa1414792

    Article  CAS  PubMed  Google Scholar 

  8. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, LycklamaàNijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW, Investigators MRCLEAN (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20. doi:10.1056/NEJMoa1411587

    Article  PubMed  Google Scholar 

  9. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD, Trial Investigators ESCAPE (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030. doi:10.1056/NEJMoa1414905

    Article  CAS  PubMed  Google Scholar 

  10. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A, Trial Investigators REVASCAT (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372(24):2296–2306. doi:10.1056/NEJMoa1503780

    Article  CAS  PubMed  Google Scholar 

  11. Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Devlin TG, Lopes DK, Reddy V, de Rochemont RdM, Jahan R, SWIFT PRIME Investigators (2015) Solitaire™ with the intention for thrombectomy as primary endovascular treatment for acute ischemic stroke (swift prime) trial: protocol for a randomized, controlled, multicenter study comparing the solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke. Int J Stroke 10(3):439–448. doi:10.1111/ijs.12459

    Article  PubMed  PubMed Central  Google Scholar 

  12. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, American Heart Association Stroke Council (2015) 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 46(10):3024–3039. doi:10.1161/STR.0000000000000074

    Article  Google Scholar 

  13. Meckel S, Herweh C (2015) Proper patient selection—the key to beneficial mechanical thrombectomy in acute stroke therapy. Cerebrovasc Dis 40(5–6):304–306. doi:10.1159/000441096

    Article  PubMed  Google Scholar 

  14. Campbell BC, Donnan GA, Lees KR, Hacke W, Khatri P, Hill MD, Goyal M, Mitchell PJ, Saver JL, Diener HC, Davis SM (2015) Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke. Lancet Neurol 14(8):846–854. doi:10.1016/S1474-4422(15)00140-4

    Article  PubMed  Google Scholar 

  15. Vagal AS, Khatri P, Broderick JP, Tomsick TA, Yeatts SD, Eckman MH (2014) Time to angiographic reperfusion in acute ischemic stroke: decision analysis. Stroke 45(12):3625–3630. doi:10.1161/STROKEAHA.114.007188

    Article  PubMed  Google Scholar 

  16. Prabhakaran S, Ruff I, Bernstein RA (2015) Acute stroke intervention: a systematic review. JAMA 313(14):1451–1462. doi:10.1001/jama.2015.3058

    Article  CAS  PubMed  Google Scholar 

  17. Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C, Mattle HP, van Zwam W, Holmin S, Tatlisumak T, Petersson J, Caso V, Hacke W, Mazighi M, Arnold M, Fischer U, Szikora I, Pierot L, Fiehler J, Gralla J, Fazekas F, Lees KR, for ESO-KSU, ESO, ESMINT, ESNR and EAN (2016) Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 11(1):134–147. doi:10.1177/1747493015609778

    Article  PubMed  Google Scholar 

  18. Hacke W (2015) The results of the recent thrombectomy trials may influence stroke care delivery: are you ready? Int J Stroke 10(5):646–650. doi:10.1111/ijs.12541

    Article  PubMed  Google Scholar 

  19. Grotta JC, Hacke W (2015) Stroke neurologist’s perspective on the new endovascular trials. Stroke 46(6):1447–1452. doi:10.1161/STROKEAHA.115.008384

    Article  PubMed  Google Scholar 

  20. European Union of Medical Specialists (2012) UEMS recommendations for acquiring “Particular qualification” in Endovascular Interventional Neuroradiology—INR. EJMINT 1212000052. http://www.ejmint.org/original-article/1212000052

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Authors and Affiliations

  1. Stroke Unit, Department of Vascular and Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy

    Valeria Caso

  2. Department of Neurology, Bogomolets National Medical University, Kiev, Ukraine

    Kateryna Antonenko

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  1. Kateryna Antonenko
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  2. Valeria Caso
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Correspondence to Valeria Caso.

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Antonenko, K., Caso, V. No space left for intravenous thrombolysis in acute stroke: PROS. Intern Emerg Med 11, 623–626 (2016). https://doi.org/10.1007/s11739-016-1457-z

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  • DOI: https://doi.org/10.1007/s11739-016-1457-z

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