From the University of Toledo Health Science Campus, OH (S.F.Z., A.C.C., M.A.J.).
AMITA Alexian Brothers, Elk Grove Village, IL (T.W.M., F.A.M.).
Stroke. 2019 Apr;50(4):1003-1006. doi: 10.1161/STROKEAHA.118.024442.
Background and Purpose- Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry. Methods- The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT. Results- A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%; P=0.13) with faster times to recanalization (100±85 versus 164±235 minutes; P=0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%; P=0.29) and mortality (42.9% versus 44.7%; P=0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%; P=0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%; P=0.02). Conclusions- Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.
背景与目的-机械血栓切除术（MT）设备已导致急性缺血性卒中伴紧急大血管闭塞患者的再灌注和临床结局得到改善；然而，只有不到三分之一的患者实现了完全再灌注。在 MT 中使用动脉内溶栓可能提供增强这些结果的机会。在此，我们评估了在北美 Solitaire 支架取栓急性卒中注册研究中，将动脉内 rtPA（重组组织型纤溶酶原激活物）作为失败的 MT 后的挽救性治疗（RT）的效果。方法-北美 Solitaire 支架取栓急性卒中注册研究招募了北美地区的多个研究中心，以提交接受 Solitaire 装置治疗的急性缺血性卒中患者的数据。在将 354 名患者的人群限制为使用 RT 和前紧急大血管闭塞后，我们比较了失败的 MT 后接受和未接受动脉内 rtPA 治疗的患者。结果-接受动脉内 rtPA RT 和未接受动脉内 rtPA RT 的患者分别有 37 名和 44 名。更多接受动脉内 rtPA RT 的患者达到了再通成功（改良脑梗死溶栓≥2b）（61.2% 比 46.6%；P=0.13），再通时间更快（100±85 分钟比 164±235 分钟；P=0.36），但无统计学意义。症状性颅内出血发生率（13.9% 比 6.8%；P=0.29）和死亡率（42.9% 比 44.7%；P=0.87）在两组之间相似。接受动脉内 rtPA RT 的患者的良好功能结局（改良 Rankin 量表评分≤2）数值更高（22.9% 比 18.4%；P=0.64）。进一步将 RT 人群限制为 M1 闭塞，并且从腹股沟穿刺到发病时间≤8 小时，在接受动脉内 rtPA RT 的患者中，再通成功率显著提高（77.8% 比 38.9%；P=0.02）。结论-作为 RT 的动脉内 rtPA 表现出相似的安全性和临床结局特征，在 M1 闭塞患者中实现了更高的再灌注率。需要前瞻性研究来阐明动脉内溶栓在 MT 中的作用。
