Treating acute large vessel occlusion stroke: to bridge or not to bridge?

• Type of Material: Article
• Authors: Yunyun Xiong, Capital Medical University; Yuesong Pan, Capital Medical University; Raul Nogueira, Emory University; Zeguang Ren, Cleveland Clinic Martin Health; Tudor G Jovin, Cooper University Hospital; Yongjun Wang, Capital Medical University
• Language: English
• Date: 2021-09-01
• Publisher: BMJ PUBLISHING GROUP
• Publication Version: Final Published Version
• Copyright Statement: © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1136/svn-2021-000952
• Title of Journal or Parent Work: STROKE AND VASCULAR NEUROLOGY
• Volume: 6
• Issue: 3
• Start Page: 324
• End Page: 327
• Grant/Funding Information: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
• Keywords: Life Sciences & Biomedicine; THROMBECTOMY; ACUTE ISCHEMIC-STROKE; stroke; Neurosciences & Neurology; Clinical Neurology; Science & Technology; thrombectomy; thrombolysis; INTRAVENOUS ALTEPLASE
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

Hot debates exist regarding whether patients who had an acute large vessel occlusion stroke (LVOS) can skip tissue plasminogen activator (tPA) and go directly to thrombectomy in comprehensive stroke centres. Three head-to-head randomised clinical trials (RCTs) of direct endovascular treatment (dEVT) versus bridge therapy (BT) with intravenous alteplase have been recently completed in the Asian population. The DIRECT-MT (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) Study randomly enrolled 656 patients who had an acute ischaemic stroke with anterior circulation LVOS across 41 large teaching hospitals in China to receive BT or dEVT within 4.5 hours after symptom onset.1 The study showed that the dEVT group was non-inferior to BT in terms of 90-day clinical outcomes (median 90-day modified Rankin Scale (mRS), 3 vs 3; OR 1.07; 95% CI 0.81 to 1.40; p=0.04).1 Likewise, the recently published DEVT (Direct Endovascular Thrombectomy vs Combined IVT and Endovascular Thrombectomy for Patients With Acute Large Vessel Occlusion in the Anterior Circulation) trial involving 234 Chinese patients who had an anterior circulation LVOS found that the rate of functional independence (90-day mRS ≥2) in dEVT group was numerically higher than that in the BT group (54.3% vs 46.6%, difference: 7.7%, 1-sided 97.5% CI: −5.1% to ∞; p=0.003 for non-inferiority).2 With prespecified non-inferiority threshold of 10% for the favourable outcome proportion difference, the trial concluded that dEVT was non-inferior to BT.2 Simultaneously published with DEVT, the SKIP (Direct Mechanical Thrombectomy in Acute LVO Stroke) trial included 204 patients who had an acute ischaemic stroke with internal carotid artery or middle cerebral artery M1 occlusions presenting within 4.5 hours of stroke onset across 23 sites in Japan.3 Favourable outcome occurred in 60 patients (59.4%) in the dEVT group and 59 patients (57.3%) in the BT group, with no significant between-group difference (difference, 2.1% (1-sided 97.5% CI −11.4% to ∞); OR 1.09 (1-sided 97.5% CI 0.63 to ∞); p=0.18 for non-inferiority).3 Noted that the trial used a reduced dose of alteplase (0.6 mg/kg), which did not show the non-inferiority to standard dose of alteplase (0.9 mg/kg).4