Literature Review

Outcomes after direct thrombectomy or combined intravenous and endovascular treatment are not different

Selected in Stroke by RIVERA Rodrigo

Authors: Abilleira S, Ribera A, Cardona P, Rubiera M, López-Cancio E, Amaro S, Rodríguez-Campello A, Camps-Renom P, Cánovas D, de Miquel MA, Tomasello A, Remollo S, López-Rueda A, Vivas E, Perendreu J, Gallofré M; Catalan Stroke Code and Reperfusion Consortium.

Reference: Stroke. 2017 Feb;48(2):375-378

Published: February 2017

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Thursday 23 March 2017
Rodrigo RIVERA

Nowadays the standard of care for ischemic stroke treatment under 4.5h is IV rTPA (IVT)  + mechanical thrombectomy (Endovascular Treatment – EVT-)  when large vessel occlusion (LVO) of anterior circulation is detected. In several stroke centers nowadays the question of the real need of previous IV treatment has been questioned, moreover if this could delay the transfer to an endovascular center and mechanical revascularization.
Time is crucial when opening an artery, and any delay could affect outcome as it has been published.

In this paper, the group from Catalonia compared two groups, one that received IVT + EVT vs EVT from a review of the SONIA registry system. The direct EVT (dEVT) group was selected when there were contraindications for IVT. The where some clinical differences between the dEVT vs the IVT group: More patients with atrial fibrillation, heart failure, oral anticoagulation, previous stroke and more delay of onset of EVT in the dEVT group. Nevertheless, after stratification, there were no differences in outcomes at 90 days, death or bleedings between the two groups.

These results are clear: there is no added difference in results when IVT treatment is used or not for LVO EVT candidates in anterior circulation strokes.

Although there are several bias and it is an observational study, the authors target a big question in stroke management nowadays.
Future randomized trials should asset this question in a better way. Thus, we should start thinking and preparing for the results. Workflow could need changes and modifications from the actual Drip and Shift model.
But countries are so different in their stroke organizations -from super organized sites to unorganized ones.

In my experience coming from a developing country in South America, there is still a lot to do even to organize a Drip & Shift model in public hospitals. Maybe there will be strong data that IV treatment adds no more benefit to EVT, but how centers and countries change and react to this will be different. Maybe there will be special considerations to set the best local strategy to manage this disease.   

> Also watch a lecture from LINNC 2016 on  Thrombectomy with or without IV thrombolysis

Rodrigo Rivera, MD
Neuroradiology Department
Instituto de Neurocirugia Dr. Asenjo
Santiago, Chile

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