REBEL Cast Ep 105: Thrombolysis Before Endovascular Therapy for LVO Acute Ischemic Stroke

In this episode of REBEL Cast, Anand Swaminathan and I sit down to discuss the utility of thrombolysis prior to Endovascular therapy for LVO acute ischemic stroke.  The discussion is broken up into two potential scenarios:

1. Not all facilities are comprehensive stroke centers
   1. In comprehensive stroke center, time from door to groin puncture will be shorter than what would be seen if transfer required
   2. Whether this makes a difference regarding use of systemic lytics is unknown
2. Non-stroke centers
   1. Application of current data to locations where endovascular therapy is only available after transfer to a larger center must be made cautiously
   2. Many hospitals will not have access to advanced imaging and may not be able to identify which patients are eligible for EVT without transfer
   3. 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

1. At a stroke center –> EVT alone
2. Not at a stroke center –> Thrombolysis then ship for EVT (Drip and Ship)
3. 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)