Chen Lining, Wu Yina, Yao Jinbiao, Wu Qiaowei, Zhang Guang, Xu Shancai, Yang Pengfei, Zhang Yongwei, Zhang Lei, Li Zifu, Xing Pengfei, Shen Hongjian, Shi Huaizhang, Liu Jianmin, Xu Chenghua, Wu Pei
Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China.
Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China.
World Neurosurg. 2025 Feb;194:123569. doi: 10.1016/j.wneu.2024.123569. Epub 2025 Jan 6.
There are still some patients with acute anterior circulation large vessel occlusion stroke experienced unsuccessful recanalization after endovascular thrombectomy (EVT). The efficacy of intravenous alteplase before thrombectomy for such patients is unknown. We performed this study to investigate whether prior intravenous alteplase could affect the outcome of patients with unsuccessful recanalization.
This is a post-hoc analysis of the DIRECT-MT trial (direct intraarterial thrombectomy in order to revascularize acute ischemic stroke patients with large vessel occlusion efficiently in Chinese Tertiary Hospitals: a multicenter randomized clinical trial). Patients with final extended thrombolysis in cerebral infarction score of 0-2a were included. Patients with successful recanalization (modified treatment in cerebral ischemia 2b-3) or could not be assessed for modified treatment in cerebral ischemia were excluded. The primary outcome was the 90-day modified Rankin Scale (mRS) score, while secondary outcomes included 90-day functional independence (mRS 0-2), recanalization (modified arterial occlusive lesion) rates at 24-72 hours by computed tomography angiography, infarction volume on computed tomography, and rates of symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage.
Among 656 randomized patients, 92 patients with unsuccessful recanalization were included, of which 55 patients underwent EVT alone (EVT group) and 37 patients underwent EVT preceded by intravenous alteplase (combination group). No statistically significant difference in the 90-day mRS score was observed between the 2 groups (adjusted common odds ratio = 1.65; 95% confidence interval, 0.76 to 3.59). The volume of infarction, the proportion of 90-day functional independence, recanalization rates at 24-72 hours, rates of symptomatic intracranial hemorrhage, and rates of asymptomatic intracranial hemorrhage were similar in both groups.
We found no evidence that prior intravenous alteplase could affect the clinical or imaging outcome in patients with acute anterior circulation large vessel occlusion stroke and unsuccessful recanalization after EVT.
仍有一些急性前循环大血管闭塞性卒中患者在血管内血栓切除术（EVT）后再通失败。血栓切除术前行静脉注射阿替普酶对此类患者的疗效尚不清楚。我们开展本研究以调查预先静脉注射阿替普酶是否会影响再通失败患者的预后。
这是DIRECT-MT试验（中国三级医院中为急性缺血性卒中伴大血管闭塞患者有效进行直接动脉内血栓切除术：一项多中心随机临床试验）的事后分析。纳入最终脑梗死溶栓扩展评分0-2a的患者。排除再通成功（改良脑缺血治疗2b-3）或无法评估改良脑缺血治疗情况的患者。主要结局为90天改良Rankin量表（mRS）评分，次要结局包括90天功能独立性（mRS 0-2）、计算机断层扫描血管造影术显示的24-72小时再通率（改良动脉闭塞病变）、计算机断层扫描梗死体积以及症状性颅内出血和无症状性颅内出血发生率。
在656例随机分组患者中，纳入92例再通失败患者，其中55例仅接受EVT（EVT组），37例在EVT前行静脉注射阿替普酶（联合组）。两组间90天mRS评分无统计学显著差异（调整后的共同优势比=1.65；95%置信区间，0.76至3.59）。两组的梗死体积、90天功能独立性比例、24-72小时再通率、症状性颅内出血发生率和无症状性颅内出血发生率相似。
我们没有发现证据表明预先静脉注射阿替普酶会影响急性前循环大血管闭塞性卒中且EVT后再通失败患者的临床或影像学结局。
