Intra-arterial thrombolytics during endovascular thrombectomy for acute ischaemic stroke in the MR CLEAN Registry

Introduction The efficacy and safety of local intra-arterial(IA)thrombolytics during endovascular thrombectomy(EVT)for large-vessel occlusions is uncertain.We analysed how often IA thrombolytics were administered in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands(MR CLEAN)Registry,whether it was associated with improved functional outcome and assessed technical and safety outcomes compared with EVT without IA thrombolytics.Methods In this observational study,we included patients undergoing EVT for an acute ischaemic stroke in the anterior circulation from the MR CLEAN Registry(March 2014-November 2017).The primary endpoint was favourable functional outcome,defined as an modified Rankin Scale score≤2 at 90 days.Secondary endpoints were reperfusion status,early neurological recovery and symptomatic intracranial haemorrhage(sICH).Subgroup analyses for IA thrombolytics as primary versus adjuvant revascularisation attempt were performed.Results Of the 2263 included patients,95(4.2%)received IA thrombolytics during EVT.The IA thrombolytics administered were urokinase(median dose,250000 IU(IQR,193750-250000))or alteplase(median dose,20 mg(IQR,12-20)).No association was found between IA thrombolytics and favourable functional outcome(adjusted OR(aOR),1.16;95%CI 0.71 to 1.90).Successful reperfusion was less often observed in those patients treated with IA thrombolytics(aOR,0.57;95%CI 0.36 to 0.90).The odds of sICH(aOR,0.82;95%CI 0.32 to 2.10)and early neurological recovery were comparable between patients treated with and without IA thrombolytics.For primary and adjuvant revascularisation attempts,IA thrombolytics were more often administered for proximal than for distal occlusions.Functional outcomes were comparable for patients receiving IA thrombolytics as a primary versus adjuvant revascularisation attempt.Conclusion Local IA thrombolytics were rarely used in the MR CLEAN Registry.In the relatively small study sample,no statistical difference was observed between groups in the rate of favourable functional outcome or sICH.Patients whom required and underwent IA thrombolytics were patients less likely to achieve successful reperfusion,probably due to selection bias.

Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke:results from the MR CLEAN Registry

Background The optimal management of ipsilateral extracranial internal carotid artery(ICA)stenosis during endovascular treatment(EVT)is unclear.We compared the outcomes of two different strategies:EVT with vs without carotid artery stenting(CAS).Methods In this observational study,we included patients who had an acute ischaemic stroke undergoing EVT and a concomitant ipsilateral extracranial ICA stenosis of≥50%or occlusion of presumed atherosclerotic origin,from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands(MR CLEAN)Registry(2014-2017).The primary endpoint was a good functional outcome at 90 days,defined as a modified Rankin Scale score≤2.Secondary endpoints were successful intracranial reperfusion,new clot in a different vascular territory,symptomatic intracranial haemorrhage,recurrent ischaemic stroke and any serious adverse event.Results Of the 433 included patients,169(39%)underwent EVT with CAS.In 123/168(73%)patients,CAS was performed before intracranial thrombectomy.In 42/224(19%)patients who underwent EVT without CAS,a deferred carotid endarterectomy or CAS was performed.EVT with and without CAS were associated with similar proportions of good functional outcome(47%vs 42%,respectively;adjusted OR(aOR),0.90;95%CI,0.50 to 1.62).There were no major differences between the groups in any of the secondary endpoints,except for the increased odds of a new clot in a different vascular territory in the EVT with CAS group(aOR,2.96;95%CI,1.07 to 8.21).Conclusions Functional outcomes were comparable after EVT with and without CAS.CAS during EVT might be a feasible option to treat the extracranial ICA stenosis but randomised studies are warranted to prove non-inferiority or superiority.