Skip to main content

Endovascular Thrombectomy preceded by intravenous Alteplase versus endovascular Thrombectomy alone in Han Chinese patients treated for acute ischemic stroke with large vessel occlusion: a single-center retrospective analysis

Abstract

Background

The American Heart Association/ American Stroke Association and the Chinese Stroke Association guidelines are recommending intravenous alteplase intervention before endovascular thrombectomy if patients are eligible to do so but the benefits of endovascular thrombectomy are different in Chinese patients with stroke than those of the white patients. The objective of the study was to compare outcomes of patients with acute ischemic stroke treated with endovascular thrombectomy with intravenous alteplase against those treated with endovascular thrombectomy alone.

Methods

A report is a retrospective analysis of comparing demographics, imaging, clinical and adverse outcomes in the Han Chinese patient who underwent mechanical thrombectomy for acute ischemic stroke with large vessel occlusion, with or without preceding intravenous alteplase administration. Patients with terminus and non-terminus intracranial occlusions and ≤ 2 points neurologic deficit underwent endovascular thrombectomy preceded by 0.9 mg/ kg intravenous alteplase (ET cohort, n = 184) and those who had contra-indication for intravenous alteplase were treated with endovascular thrombectomy alone (EA cohort, n = 141).

Results

The most common procedural complications were embolization into new territory (p = 0.866) and uneventful artery vasospasm (p = 0.712). Insignificant differences were reported for any procedural complications (p = 0.991), imaging outcomes, the modified Rankin scale score (p = 0.663), and death (28 vs. 24, p = 0.761) within 90 days between patients of both cohorts. At the discharge of the hospital, the National Institutes of Health Stroke Scale scores of patients of the ET cohort were lower than those of the EA cohort (8.58 ± 3.79 vs. 10.23 ± 4.97, p = 0.003). The Barthel Index of survivors at 90 days after endovascular thrombectomy was higher for patients of the ET cohort than those of the EA cohort (87.47 ± 12.58 vs. 84.01 ± 13.47, p = 0.032). The most common adverse effect was asymptomatic intracranial hemorrhage (p = 0.297). Insignificant differences were reported for adverse effects after thrombectomy between survivors of both cohorts.

Conclusions

Outcome measures in Han Chinese patients with acute ischemic stroke treated with endovascular thrombectomy alone were statistically the same as those treated with endovascular thrombectomy plus intravenous alteplase.

Level of evidence

Iii

Technical efficacy stage

4.

Peer Review reports

Background

Stroke is the major cause of death in China [1] and the prevalence of stroke has risen in the Chinese population in recent years [2]. These have imposed a heavy burden on the healthcare system of China [1]. Endovascular thrombectomy is used as a part of the standard treatment(s) in patients of acute ischemic stroke in the anterior cerebral circulation due to large-vessel occlusion [3]. Alteplase is generally administered intravenously in cases of endovascular thrombectomy [2]. The exact role of alteplase before and during endovascular thrombectomy is uncertain. Probably, alteplase increases reperfusion of the ischemic area and dissolves thrombi after endovascular thrombectomy [4]. Pooled analyses [5, 6], a meta-analysis [7], and the DEVT trial [8] suggest equivalent effects of endovascular thrombectomy alone and combined treatments of endovascular thrombectomy with intravenous alteplase intervention. However, a randomized trial [2], a meta-analysis [9], and a SKIP trial [10] show the superior effect of endovascular thrombectomy combined with intravenous alteplase intervention compared to endovascular thrombectomy alone. Intravenous alteplase intervention with endovascular thrombectomy is effective for emergency revascularization [11] but may have changes of coagulation abnormalities and hemorrhagic complications [12]. Further, intravenous alteplase intervention has a poor response as compared to the endovascular thrombectomy in the management of stroke in patients with large vessel occlusion. In most cases, intravenous alteplase intervention induces partial recanalization, since stroke patients often have a large thrombus burden. Thus, the presence of a proximal arterial occlusion does not necessarily lead to alteplase intervention failure, since some degree of recanalization can occur even with large thrombi [13]. The American Heart Association/ American Stroke Association [14] and the Chinese Stroke Association guidelines [15] are recommending intravenous alteplase intervention before endovascular thrombectomy if patients are eligible to do so but the beneficial effects of endovascular thrombectomy are different in Chinese patients with stroke than those of white patients because more numbers of cases with intracranial atherosclerosis among Chinese patients with stroke [16]. Therefore, there is uncertainty about the favorable and unfavorable effects of intravenous administration of alteplase before endovascular thrombectomy in Chinese patients with acute ischemic stroke because the currently available data are inconclusive regarding the efficacy of mechanical thrombectomy alone or in combination with intravenous thrombolysis.

The objectives of the retrospective study were to compare procedural complications, imaging outcomes, the ischemic stroke conditions, functional outcome measures, health status, adverse effects, and death of Han Chinese patients treated with endovascular thrombectomy with intravenous alteplase against those treated with endovascular thrombectomy alone for acute ischemic stroke with large vessel occlusion.

Methods

Inclusion criteria

Patients 18 years and above of acute ischemic stroke who had terminus and non-terminus intracranial occlusions of the internal carotid artery and/ or occlusions of the first or proximal second segment of the middle cerebral artery (the results as per the computed tomographic angiography) and had a neurologic deficit 2 points or less (according to the modified Rankin scale score) were included in the analysis.

Exclusion criteria

Patients who had the modified Rankin scale score for disability more than 2 before stroke were excluded from the analysis.

Sample size calculation

The sample size was calculated based on the assumption that endovascular thrombectomy with/ without intravenous alteplase intervention would be improved the modified Rankin scales for disability of at least 10% of patients, 80% power calculation (β = 0.2), two-sided type-I error (α = 0.05), and at 95% of confidence level. The sample size (minimum number of patients required in each cohort) was 105.

Cohorts

A total of 184 patients underwent endovascular thrombectomy using AngioJet AVX Thrombectomy Catheter (Boston Scientific Corporation, Boston, MA, USA) preceded by 0.9 mg/ kg intravenous alteplase (10% bolus and 90% infusion throughout 1 h) administered within 4.5 h after symptom onset (EA cohort). A total of 141 patients have contra-indication for intravenous alteplase according to the American Heart Association-American Stroke Association guidelines [17] (serious head trauma, prior stroke, hemorrhagic coagulopathy, or receiving anticoagulant medications), so they underwent endovascular thrombectomy only (ET cohort).

Data collection

Data regarding procedural complications, imaging outcomes before thrombectomy and after endovascular thrombectomy, the National Institutes of Health Stroke Scale score before endovascular thrombectomy, 1-day after, and one week after of endovascular thrombectomy (or discharge of hospital), the modified Rankin scale score before endovascular thrombectomy and at 90 days after endovascular thrombectomy, death of patients within 90 days after endovascular thrombectomy, the Barthel Index at 90 days after endovascular thrombectomy, health status at 90 days after endovascular thrombectomy, recanalization at 3 days after endovascular thrombectomy, the final lesion volume at the discharge of hospital, and adverse effects within 90 days after endovascular thrombectomy were retrospectively collected from the patients’ records of institutes.

Ischemic stroke condition

The severity of the ischemic stroke condition was assessed by the National Institutes of Health Stroke Scale score. It was in the range of 0–42. 0–6: mild symptoms, 7–14: moderate symptoms, and ≥ 15 severe symptoms [18].

Functional outcomes

The modified Rankin scale score

It was used for the assessment of the severity of the disability. 0: no disability, 1: no significant disability but has symptoms, 2: slight disability to perform the daily activity, 3: able to walk without assistance or require some help (moderate disability), 4: unable to walk without assistance, and 5: requires constant nursing care for daily activity [19].

Imaging outcomes

The Alberta stroke program early computed tomography score

It is a measure of the extent of early cerebral ischemia. Scores range from 0 to 10, with higher scores indicating early ischemic changes are less [2].

Reperfusion

The extended Thrombolysis in Cerebral Infarction score was preferred for evaluation of reperfusion of the occluded vascular territory using digital subtraction angiography. The score is ranged from 0 to 3. 0: no antegrade reperfusion, 1: limited antegrade reperfusion, 2a: less than 50% antegrade reperfusion, 2b: 50% or more but less than 90% antegrade reperfusion, 2c: 90% or more antegrade reperfusion, and 3: complete (100%) antegrade reperfusion [20].

Recanalization

The modified Arterial Occlusive Lesion score as per the computed tomographic angiography results was used to defined recanalization. The score ranges from 0 to 3. 0: No recanalization, 1: partial recanalization without passage of contrast agent, 2: partial recanalization with the passage of contrast agent, and 3: complete recanalization [11].

The final lesion volume

The final lesion volume was measured by the non-contrast computed tomography. Automatic measurement software was used for the measurement of volume.

Quality of life

The Barthel index

It is the 10-item scale of 10 basic activities of self-care and mobility. The activities included for consideration were urinary bladder management, bowel management, toilet management, bathing, dressing, grooming, feeding, walking, transfer, and ascending and descending staircases. Each item has a 0 to 10 scale. If an individual item was performed by patients without assistance of anything, considered as maximum 10, and the item performed using help was considered as 0. The total score of the Barthel Index was 100. Score 0 indicating severe disability that interferes with daily activities and a score of 95 or more indicating no disability interferes with daily activities [21].

Health status

Health status was accessed using the 5-Dimension 5-Level Self-Report Questionnaire. Five dimensions were mobility, self-care, usual activity, pain/ discomfort, and anxiety/ depression. Five levels were 1: normal, 2: slight problem, 3: moderate problem, 4: severe problem, 5: extreme problem. It is ranged from − 0.39 to 1. 0: death, 1: full health, and a negative value indicates a condition worse than death [22].

Adverse effects

Heidelberg criteria were used for the evaluation of intracranial hemorrhage [23].

Statistical analysis

InStat 3.0.1, GraphPad software, USA was used for statistical analysis. Unpaired t-test was performed for continuous variables and Fischer exact test or the Chi-square test of Independence was performed for constant variables. If the p-value was less than 0.05, the results were considered significant.

Results

Study population

From January 2, 2018, to August 11, 2019, a total of 330 Han Chinese patients underwent endovascular thrombectomy alone or with intravenous alteplase for management of the acute ischemic stroke at the People’s Hospital of Bozhou, Bozhou Hospital Affiliated to Anhui Medical University, Bozhou, Anhui, China. Among them, 5 patients had the modified Rankin scale score for disability more than 2 before stoke treatment(s). Therefore, these patients were excluded from the analysis. Data regarding imaging outcomes, the ischemic stroke condition, the functional outcomes, death of patients within 90 days after endovascular thrombectomy, health status, recanalization, the final lesion volume, and adverse effects within 90 days after endovascular thrombectomy of the total of 325 Han Chinese patients were retrospectively collected from the patients’ records of institutes and analyzed. The flow diagram for the treatment of acute ischemic stroke is presented in Fig. 1.

Fig. 1
figure1

The flow diagram of management of acute ischemic stroke

Characteristics of patients

There were no significant differences for the clinical and demographical characteristics of patients before treatment(s) (for stroke) between cohorts (p > 0.05 for all). The details of the clinical and demographical characteristics of patients before treatment(s) (for stroke) are reported in Table 1. The reasons for intravenous alteplase treatment contraindications for the patients of the ET cohort are summarized in Table 2.

Table 1 The clinical and demographical characteristics of patients before treatment(s) (for stroke)
Table 2 Summarizing the reasons of intravenous alteplase treatment contraindications

Procedural complications

The most common procedural complications were embolization into a new territory and uneventful artery vasospasm. There were no significant differences for the any procedural complications between both cohorts (p = 0.991). The details of procedural complications are reported in Table 3.

Table 3 Procedural complications

Time metrics

Time from door to the interpretation of computed tomography angiography for patients of the EA cohort was 17.18 ± 1.15 min and that for patients of the ET cohort was 16.95 ± 1.51 (p = 0.119). The onset time to groin puncture for patients of the EA cohort was 53.15 ± 5.8 min and that for patients of the ET cohort was 52.31 ± 6.1 min (p = 0.207). For patients of the EA cohort, the onset time to intravenous alteplase treatment decision was 90.15 ± 28.5 min, and door to intravenous alteplase treatment time was 54.52 ± 2.15 min.

Outcome measures

The ischemic stroke conditions

There was no significant difference for the National Institutes of Health Stroke Scale scores of survivors at one day after endovascular thrombectomy between both cohorts (12.39 ± 4.20 (5–20; median: 12) vs. 12.36 ± 4.30 (5–20; median: 12), p = 0.947). However, one week after endovascular thrombectomy or discharge from hospital, the National Institutes of Health Stroke Scale scores of patients of the ET cohort were lower than those of the EA cohort (8.58 ± 3.79 (2–18; median: 8) vs. 10.23 ± 4.97 (2–18; median: 10), p = 0.003). The details of the National Institutes of Health Stroke Scale scores of survivors are reported in Fig. 2.

Fig. 2
figure2

The National Institutes of Health Stroke Scale scores of patients. 0–6: mild symptoms, 7–14: moderate symptoms, and ≥ 15 severe symptoms

Functional and imaging outcome measures

There was no significant difference for the modified Rankin scale score of survivors at 90 days after endovascular thrombectomy between both cohorts (p = 0.663, Fig. 3). There were no significant differences for the reperfusion of survivors at one day after endovascular thrombectomy between both cohorts (p = 0.124), the recanalization of survivors at 3 days after endovascular thrombectomy between both cohorts (p = 0.384), and the final lesion volume of survivors at the discharge of hospital (42.15 ± 13.18 mL vs. 40.22 ± 11.18 mL, p = 0.203).

Fig. 3
figure3

The modified Rankin scale score of survivors at 90 days. 0: no disability, 1: no significant disability but has symptoms, 2: slight disability to perform the daily activity, 3: able to walk without assistance or require some help (moderate disability), 4: unable to walk without assistance, and 5: requires constant nursing care for daily activity

Quality of life

The Barthel index

The Barthel Index of survivors at 90 days after endovascular thrombectomy was higher for patients of the ET cohort than those of the EA cohort (87.47 ± 12.58 vs. 84.01 ± 13.47, p = 0.032). The details of the Barthel Index score of survivors are reported in Fig. 4.

Fig. 4
figure4

The Barthel Index score of survivors at 90 days after endovascular thrombectomy

Health status

5-Dimension 5-Level Self-Report Questionnaire of survivors at 90 days after endovascular thrombectomy was higher for patients of the ET cohort than those of the EA cohort (0.86 ± 0.04 vs. 0.85 ± 0.04, p = 0.005). The details of the 5-Dimension 5-Level Self-Report Questionnaire of survivors are reported in Fig. 5.

Fig. 5
figure5

5-Dimension 5-Level Self-Report Questionnaire of survivors at 90 days after endovascular thrombectomy with/ without intravenous alteplase intervention. 0: death, 1: full health, and a negative value indicates a condition worse than death

The details of all outcome measures after endovascular thrombectomy are reported in Table 4.

Table 4 Functional and imaging outcome measures after endovascular thrombectomy with/ without intravenous alteplase intervention

Adverse effects

The most common reported adverse effect within 90 days after endovascular thrombectomy was asymptomatic intracranial hemorrhage. There were no significant differences in the reported adverse effects between both cohorts. The details of adverse effects are reported in Table 5.

Table 5 Adverse effects within 90 days after endovascular thrombectomy with/ without intravenous alteplase intervention

Mortality

A total of 28 (15%) patients from the EA cohort and 24 (17%) patients from the EA cohort have died within 90 days after endovascular thrombectomy (p = 0.761).

Discussion

The current study reported statistically insignificant differences for the modified Rankin scale score, procedural complications, imaging outcomes, and adverse effects of survivors within 90 days after thrombectomy and death within 90 days after thrombectomy between patients who underwent endovascular thrombectomy with intravenous alteplase intervention and those who underwent without intravenous alteplase intervention. The non-inferior outcome measures of the study were consistent with those of a randomized trial [2], the DEVT trial [8], pooled analyses [5, 6] but not consistent with those of a meta-analysis [9], a randomized trial [11], and a SKIP trial [10]. The reason for these contradictory results between the current study and those of a meta-analysis [9] and those of a SKIP trial [10] is different inclusion criteria of the studies and that for the contradictory results between the current study and those of a randomized trial [11] is unbalanced randomization of a trial. Most notably, the contraindication to alteplase would confound the cohort of patients who did not get alteplase and not allow for a clean comparison with the alteplase plus endovascular thrombectomy cohort. A brief time between administering intravenous alteplase and endovascular thrombectomy procedure did not express a significant effect of intravenous alteplase in patients [24]. The results of the current study do not rule out the benefit of intravenous alteplase intervention but patients who underwent endovascular thrombectomy without intravenous alteplase have better results than those who underwent endovascular thrombectomy with intravenous alteplase intervention.

The current study reported unfavorable effects of administering intravenous alteplase before endovascular thrombectomy on the National Institutes of Health Stroke Scale scores, the Barthel Index score, and the 5-Dimension 5-Level Self-Report Questionnaire of survivors. The inferior outcome measures of the current study were consistent with a meta-analysis [7] but not consistent with those of randomized trials [2, 11]. The large sample size (type-II error) of a randomized trial [2] (disease-oriented evidence requires smaller sample sizes for analyses [25]) and unbalanced randomization of a trial [11] are responsible for contradictory results. The outcomes of endovascular thrombectomy with or without intravenous alteplase are different in Chinese patients with acute ischemic stroke than those of white patients [16]. Administering intravenous alteplase before endovascular thrombectomy may worsen the health status of Han Chinese patients with acute ischemic stroke. However, more data and work need to be validated because 49% patients of the ET cohort had received anticoagulant medications.

The current study described a series of patients undergoing mechanical thrombectomy using the AngioJET system, which is a system used for peripheral thrombectomy. The Stroke thrombectomy systems used in all trials that established the benefits of endovascular treatment were performed with a stent- retriever or a large-bore aspiration system [26]. The technique used is not commonly used, no randomized controlled trials have used this device, and there is no validation for intracerebral use in ischemic arterial stroke. Mechanical thrombectomy has been recommended by European guidelines 7 and by the National Institute for Health and Care Excellence, and as the preferred treatment of acute ischemic stroke, particularly for large-vessel occlusions [27]. The AngioJet Thrombectomy system offers catheters for treating vessels of ≥1.5 mm clot burdens. In the current study, clots were larger, and a stent-retriever or a large-bore aspiration system is not a much effective technique when large clots are targeted [28]. Therefore, the AngioJET system was used to treat ischemic arterial stroke.

There are several limitations of the study that have to be reported, for example, retrospective study and lack of randomized trial. In the other limitations of the study, the management of acute ischemic stroke of patients was performed according to the American Heart Association-American Stroke Association guidelines [17], in which stent retrievers were performed before endovascular thrombectomy and 0.9 mg/ kg intravenous alteplase (10% bolus and 90% infusion throughout 1 h) administered. Aspiration catheters and tenecteplase were not used for the management of acute ischemic stroke patients. The results of the current study on Han Chinese patients are not generalizable to the other than Han Chinese people because there are differences in the prevalence of stroke between the Chinese population and white people. Also, the prehospital triage method is more complicated in mainland China than the Western countries. The reperfusion rate is disease-related proof [25]. Improvements in reperfusion (64% survivors from the EA cohort and 61% survivors from the ET cohort were reported partial or complete recanalization (the modified Arterial Occlusive Lesion score ≥ 1) at 3 days after endovascular thrombectomy) was reported but these did not translate into clinical benefits (patients of both cohorts reported moderate clinical outcomes; only 38% survivors from the EA cohort and 39% from survivors from the ET cohort had the modified Rankin scale score between 0 and 2 at 90 days after endovascular thrombectomy). The reasons for these are unclear. Of greater interest was the reported use of the AngioJet AVX Thrombectomy Catheter for acute ischemic stroke thrombectomy. This is not conventionally used for cerebral arterial occlusive lesions in Europe or North America because that is a pharmaco-mechanical peripheral thrombectomy device with an active aspiration that is not released for neurovascular use in stroke. This experience may be of interest, particularly in comparison to either direct aspiration or stent-retriever thrombectomy, the two primary technical approaches used. The current study compared cohorts that were treated with intravenous plus intraarterial therapy (when indicated) versus a cohort that had a contraindication for intravenous treatment (serious head trauma, prior stroke, hemorrhagic coagulopathy, or receiving anticoagulant medications). Therefore, they are different populations, and a direct comparison of results is not possible.

Conclusions

This study attempts to address the knowledge gap regarding the impact (positive or negative) of intravenous alteplase treatment along with mechanical thrombectomy among the Han Chinese population. Endovascular thrombectomy alone treatment is statistically the same as endovascular thrombectomy with intravenous alteplase treatment regarding procedural complications, imaging outcomes, and the modified Rankin scale score in Han Chinese patients with acute ischemic stroke. Endovascular thrombectomy with intravenous alteplase treatment may have unfavorable effects on the ischemic stroke condition, functional outcome measures, and 5-Dimension 5-Level Self-Report Questionnaire of survivors during the follow-up period. However, it is appropriate to follow the American Heart Association/ American Stroke Association and the Chinese Stroke Association guidelines that patients with acute ischemic stroke should receive alteplase before endovascular thrombectomy if a patient is eligible for the same until the new recommendations. The current study adds to the current understanding of whether alteplase confers benefit before endovascular thrombectomy, which does not aim to address the other recently published studies on Han Chinese patients. However, there may be a selection bias and associated limitations of a retrospective study and needs to be validated in a large registry-based study or randomized control trial.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

EA cohort:

Patients have received endovascular thrombectomy with intravenous alteplase, ET cohort

Patients have been treated with endovascular thrombectomy alone

SD:

Standard deviation

References

  1. 1.

    Xu J, Zhang Y, Wei H, Xu Y, Wang M, Cai Z, et al. A comparison of rt-PA thrombolysis guidelines between China and the USA: are changes needed? Neurol Res. 2015;37(1):57–63. https://doi.org/10.1179/1743132814Y.0000000415.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, et al. DIRECT-MT Investigators. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382(21):1981–93.

    CAS  Article  Google Scholar 

  3. 3.

    Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.

    Article  Google Scholar 

  4. 4.

    Tsivgoulis G, Katsanos AH, Schellinger PD, Köhrmann M, Varelas P, Magoufis G, et al. Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions. Stroke. 2018;49(1):232–5. https://doi.org/10.1161/STROKEAHA.117.019261.

    Article  PubMed  Google Scholar 

  5. 5.

    Bellwald S, Weber R, Dobrocky T, Nordmeyer H, Jung S, Hadisurya J, et al. Direct mechanical intervention versus bridging therapy in stroke patients eligible for intravenous thrombolysis: a pooled analysis of 2 registries. Stroke. 2017;48(12):3282–8. https://doi.org/10.1161/STROKEAHA.117.018459.

    Article  PubMed  Google Scholar 

  6. 6.

    Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Clark W, Dávalos A, et al. Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the SWIFT and STAR studies. JAMA Neurol. 2017;74(3):268–74. https://doi.org/10.1001/jamaneurol.2016.5374.

    Article  PubMed  Google Scholar 

  7. 7.

    Kaesmacher J, Mordasini P, Arnold M, López-Cancio E, Cerdá N, Boeckh-Behrens T, et al. Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis. J Neurointerv Surg. 2019;11(1):20–7. https://doi.org/10.1136/neurintsurg-2018-013834.

    Article  PubMed  Google Scholar 

  8. 8.

    Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W, et al. DEVT Trial Investigators. Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke: The DEVT randomized clinical trial. JAMA. 2021;25:234–43.

    Article  Google Scholar 

  9. 9.

    Katsanos AH, Malhotra K, Goyal N, Arthur A, Schellinger PD, Köhrmann M, et al. Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions. Ann Neurol. 2019;86(3):395–406. https://doi.org/10.1002/ana.25544.

    Article  PubMed  Google Scholar 

  10. 10.

    Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, et al. SKIP Study Investigators. Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: The SKIP randomized clinical trial. JAMA. 2021;325:244–53.

    Article  Google Scholar 

  11. 11.

    Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.

    Article  Google Scholar 

  12. 12.

    Fischer U, Kaesmacher J, Mendes Pereira V, Chapot R, Siddiqui AH, Froehler MT, et al. Direct mechanical thrombectomy versus combined intravenous and mechanical thrombectomy in large-artery anterior circulation stroke: a topical review. Stroke. 2017;48(10):2912–8. https://doi.org/10.1161/STROKEAHA.117.017208.

    Article  PubMed  Google Scholar 

  13. 13.

    Tsivgoulis G, Katsanos AH, Alexandrov AV. Reperfusion therapies of acute ischemic stroke: potentials and failures. Front Neurol. 2014;5:1–10. https://doi.org/10.3389/fneur.2014.00215.

    Article  Google Scholar 

  14. 14.

    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 update to the 2018 guidelines for the early Management of Acute Ischemic Stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418. https://doi.org/10.1161/STR.0000000000000211.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Liu L, Chen W, Zhou H, Duan W, Li S, Huo X, et al. Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of ischaemic cerebrovascular diseases. Stroke Vasc Neurol. 2020;5(2):159–76. https://doi.org/10.1136/svn-2020-000378.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Wang Y, Zhao X, Liu L, Soo YO, Pu Y, Pan Y, et al. Prevalence and outcomes of symptomatic intracranial large artery stenoses and occlusions in China: the Chinese intracranial atherosclerosis (CICAS) study. Stroke. 2014;45(3):663–9. https://doi.org/10.1161/STROKEAHA.113.003508.

    Article  PubMed  Google Scholar 

  17. 17.

    Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. American Heart Association Stroke Council. 2015 American Heart Association/American Stroke Association focused update of the 2013 Guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020–5.

    CAS  Article  Google Scholar 

  18. 18.

    Li F, Yang L, Yang R, Xu W, Chen FP, Li N, et al. Ischemic stroke in young adults of northern China: characteristics and risk factors for recurrence. Eur Neurol. 2017;77(3–4):115–22. https://doi.org/10.1159/000455093.

    Article  PubMed  Google Scholar 

  19. 19.

    Chen J, Jin W, Dong WS, Jin Y, Qiao FL, Zhou YF, et al. Effects of home-based telesupervising rehabilitation on physical function for stroke survivors with hemiplegia: a randomized controlled trial. Am J Phys Med Rehabil. 2017;96(3):152–60. https://doi.org/10.1097/PHM.0000000000000559.

    Article  PubMed  Google Scholar 

  20. 20.

    Goyal M, Fargen KM, Turk AS, Mocco J, Liebeskind DS, Frei D, et al. 2C or not 2C: defining an improved revascularization grading scale and the need for standardization of angiography outcomes in stroke trials. J Neurointerv Surg. 2014;6(2):83–6. https://doi.org/10.1136/neurintsurg-2013-010665.

    Article  PubMed  Google Scholar 

  21. 21.

    Liu F, Tsang RC, Zhou J, Zhou M, Zha F, Long J, et al. Relationship of Barthel index and its short form with the modified Rankin scale in acute stroke patients. J Stroke Cerebrovasc Dis. 2020;29(9):1–8. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105033.

    Article  Google Scholar 

  22. 22.

    Lam C, Chin WY, Wong CKH, Or K, Fong DYT, Cheung JPY, et al. Effectiveness of routine measurement of health-related quality of life in improving the outcomes of patients with musculoskeletal problems-a cluster randomised controlled trial: protocol paper. BMJ Open. 2020;10(12):1–9. https://doi.org/10.1136/bmjopen-2020-040373.

    Article  Google Scholar 

  23. 23.

    von Kummer R, Broderick JP, Campbell BC, Demchuk A, Goyal M, Hill MD, et al. The Heidelberg bleeding classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke. 2015;46(10):2981–6. https://doi.org/10.1161/STROKEAHA.115.010049.

    Article  Google Scholar 

  24. 24.

    Albers GW. Thrombolysis before Thrombectomy - to be or DIRECT-MT? N Engl J Med. 2020;382(21):2045–6. https://doi.org/10.1056/NEJMe2004550.

    Article  PubMed  Google Scholar 

  25. 25.

    Spiegel RS, Radecki RP. tPA an unnecessary adjunct to endovascular Thrombectomy? An analysis of the DIRECT-MT trial: august 2020 annals of emergency medicine journal Club. Ann Emerg Med. 2020;76(2):245–6. https://doi.org/10.1016/j.annemergmed.2020.06.028.

    Article  PubMed  Google Scholar 

  26. 26.

    Choi JW, Han M, Park JH, Jung WS. Effect of manual aspiration thrombectomy using large-bore aspiration catheter for acute basilar artery occlusion: comparison with a stent retriever system. BMC Neurol. 2020;20(1):1–7. https://doi.org/10.1186/s12883-020-02013-7.

    CAS  Article  Google Scholar 

  27. 27.

    Candio P, Violato M, Leal J, Luengo-Fernandez R. Cost-effectiveness of mechanical thrombectomy for treatment of nonminor ischemic stroke across Europe. Stroke. 2021;52(2):664–73. https://doi.org/10.1161/STROKEAHA.120.031027.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Matsuda Y, Okada H, Chung J, Webster Crowley R, Lopes DK. Novel balloon-and-aspiration method for cerebral venous sinus thrombosis: dental-floss technique. Neurosurg Focus. 2017;42(4):1–5. https://doi.org/10.3171/2017.1.FOCUS16519.

    Article  Google Scholar 

Download references

Acknowledgments

The authors are thankful for the medical, surgical, and non-medical staff of the People’s Hospital of Bozhou, Bozhou Hospital Affiliated with Anhui Medical University, Bozhou City, Anhui Province, China.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Affiliations

Authors

Contributions

All authors have read and approved the manuscript for publication. RH was a project administrator, contributed to supervision, resources, methodology, and the literature review of the study. BL contributed to software, resources, visualization, methodology, and the literature review of the study. YY contributed to conceptualization, resources, data curation, methodology, and the literature review of the study. GW contributed to the investigation, formal analysis, methodology, resources, and the literature review of the study. XY contributed to formal analysis, data curation, methodology, and the literature review of the study, draft, and edited the manuscript for intellectual content. All authors agree to be accountable for all aspects of work ensuring integrity and accuracy.

Corresponding author

Correspondence to Xiuxia Yan.

Ethics declarations

Consent to publication

None.

Ethics approval and consent to participate

The designed protocol (AMUCL2421 dated 6 January 2021) was approved by the Anhui Medical University review board and the Chinese Stroke Society. Informed consent has been obtained by patients or their lawful representatives. The study reporting has adhered to the law of China, and the V2008 Declarations of Helsinki.

Competing interests

The authors of this work have nothing to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Han, R., Li, B., Yue, Y. et al. Endovascular Thrombectomy preceded by intravenous Alteplase versus endovascular Thrombectomy alone in Han Chinese patients treated for acute ischemic stroke with large vessel occlusion: a single-center retrospective analysis. BMC Neurol 21, 375 (2021). https://doi.org/10.1186/s12883-021-02401-7

Download citation

Keywords

  • Alteplase
  • Intracranial hemorrhage
  • Modified Rankin scale score
  • Recanalization
  • Stroke
  • Thrombectomy