- Not all facilities are comprehensive stroke centers
- In comprehensive stroke center, time from door to groin puncture will be shorter than what would be seen if transfer required
- Whether this makes a difference regarding use of systemic lytics is unknown
- Non-stroke centers
- Application of current data to locations where endovascular therapy is only available after transfer to a larger center must be made cautiously
- Many hospitals will not have access to advanced imaging and may not be able to identify which patients are eligible for EVT without transfer
- These centers may need to give thrombolysis prior to transfer as there is usually delay in getting EVT
REBEL Cast Ep105: Thrombolysis Before Endovascular Therapy for LVO Acute Ischemic Stroke
Clinical Question: Is systemic thrombolysis needed prior to endovascular therapy for LVO strokes presenting within 4.5hrs of onset?
Previous Trials:
Direct-MT (NEJM 2020) [Link is HERE]
- RCT
- 1586 pts
- Alteplase 0.9mg/kg
- In China
- Endovascular therapy alone non-inferior
- Intracranial occlusion 37.7%
DEVT (JAMA 2021) [Link is HERE]
- RCT
- 509 pts
- Alteplase 0.9mg/kg
- In China
- Stroke Center
- Endovascular therapy alone non-inferior
- Intracranial occlusion 15%
SKIP (JAMA 2021) [Link is HERE]
- 204pts
- RCT
- Alteplase 0.6mg/kg
- In Japan
- Stroke Center
- Endovascular therapy alone failed to demonstrate non-inferiority
MR CLEAN-NO (NEJM 2021) [Link is HERE]
- RCT
- 547pts
- Alteplase 0.9mg/kg
- In Europe
- No superiority to alteplase followed by EVT
- Endovascular therapy alone failed to demonstrate non-inferiority
3 Things to Consider
- At a stroke center –> EVT alone
- Not at a stroke center –> Thrombolysis then ship for EVT (Drip and Ship)
- Tenecteplase 0.25mg/kg to max of 25mg vs alteplase
-
- Higher fibrin specificity
- Longer half-life than alteplase
- Single bolus administration
- Meta-analysis of 2031pts (6RCTs + 2 observational trials) [Link is HERE]
- Trend toward excellent functional outcome (not statistically significant)
- Tenecteplase with higher rates of recanalization (NNT = 9)
- Tenecteplase with higher rates of early neurologic improvement (NNT = 10)
- No difference in ICH, sICH, or mortality
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)
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