Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, Munson Healthcare, Traverse City, Michigan, USA.
University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
World Neurosurg. 2020 Sep;141:e447-e452. doi: 10.1016/j.wneu.2020.05.187. Epub 2020 May 29.
Although still recommended, using intravenous tissue plasminogen activator (IV-tPA) for large vessel occlusions (LVOs) has been questioned in the era of mechanical thrombectomy (MT). We sought to determine the impact of IV-tPA if used before MT.
We used a single-institution, prospectively maintained stroke database from July 2017 through June 2019. All patients undergoing MT with or without IV-tPA treatment for LVO with pretreatment computed tomography angiography (CTA) head and neck were included. We compared the initial CTA images of clot location and morphology to the angiographic findings visualized on the first injection before mechanical intervention.
Eighty patients were included. About a third (33%) received IV-tPA before thrombectomy. Among patients receiving IV-tPA, significantly more, 29% versus 5.6% without IV-tPA, experienced distal clot migration or changes in morphology between first CTA acquisition and first angiographic run before thrombectomy (P = 0.006). On logistic regression IV-tPA was the only significant predictor of clot migration (P = 0.024). Of note, clot migration due to IV-tPA use was not associated with superior recanalization rates or outcomes in this analysis (P = 0.27). Original site clot resolution was noted in 8% (2/24) of patients who received IV-tPA; however, distal M4/5 embolic cutoffs were noted in both patients.
IV-tPA administration for LVO has a low rate of primary recanalization with risk of distal embolic phenomenon often still requiring MT. No significant changes in patient outcomes were noted in this study due to clot migration. Larger studies will be necessary to determine if IV-tPA plus MT truly benefits entire clot removal versus MT alone.
在机械取栓 (MT) 时代，尽管仍推荐使用静脉内组织型纤溶酶原激活剂 (IV-tPA) 治疗大血管闭塞 (LVOs)，但这种方法已受到质疑。我们旨在确定在 MT 之前使用 IV-tPA 的影响。
我们使用了一家机构从 2017 年 7 月至 2019 年 6 月前瞻性维护的卒中数据库。所有接受 MT 治疗且有或无 LVO 预处理 CT 血管造影 (CTA) 头颈部治疗的患者均包括在内。我们比较了初始 CTA 图像上的血栓位置和形态与机械干预前第一次注射的血管造影发现。
80 例患者被纳入研究。约三分之一（33%）的患者在 MT 前接受了 IV-tPA 治疗。在接受 IV-tPA 的患者中，有更多的患者（29%）与未接受 IV-tPA 的患者（5.6%）相比，在 MT 前第一次 CTA 采集和第一次血管造影运行之间，出现远端血栓迁移或形态改变（P = 0.006）。在 logistic 回归中，IV-tPA 是唯一显著的血栓迁移预测因子（P = 0.024）。值得注意的是，在本分析中，由于使用 IV-tPA 导致的血栓迁移与更好的再通率或结果无关（P = 0.27）。在接受 IV-tPA 的 24 例患者中，有 8%（2 例）患者出现原部位血栓溶解；然而，在这 2 例患者中都出现了远端 M4/5 栓塞截断。
IV-tPA 治疗 LVO 的再通率较低，且存在远端栓塞现象的风险，往往仍需要 MT。在本研究中，由于血栓迁移，患者的结局没有明显变化。需要更大的研究来确定 IV-tPA 加 MT 是否确实优于 MT 单独治疗，是否能真正有助于完全清除血栓。
