Introduction: Systemic Thrombolysis with tissue Plasminogen Activator (tPA) has been an established therapy for ischemic stroke for more than 20 years, with limited effect on large vessel occlusions. New catheter-based techniques allow high revascularization rates were tPA fails. Systemic thrombolysis remains the standard treatment of care and endovascular treatment is newly established as therapy for large vessel occlusion or rescue therapy after unsuccessful revascularization by thrombolysis. Patients with large vessel occlusions have a very limited reperfusion rate and benefit from direct endovascular treatment (EVT). In this real-life study, patients are compared regarding their outcome after systemic thrombolysis with rescue endovascular treatment in comparison to direct endovascular treatment for large vessel occlusions.
Patients and Methods: Patients are categorized retrospectively by their treatment. Data on 120 patients was used, with the exclusion of 13 patients. Analyses were performed according to mRS and EQ5D after 7 days as well as 10 to 14 weeks. Primary observed outcome was quality of life and mRS after 10 to 14 weeks.
Results: Regarding mRS, initial outcome after 7 days is more successful with direct EVT, but prior thrombolysis shows additional improvement after 10 to 14 weeks. There is no statistically relevant difference in patients that received prior tPA and rescue endovascular treatment in comparison to direct endovascular treatment after 10 to 14 weeks. EQ5D on the other hand shows higher life quality, according to better functional outcome after endovascular treatment. Regarding the primary endpoint of the study, there is no statistically relevant difference between both study groups at the end point of the study.
Discussion: While direct endovascular treatment shows an immediate benefit for patients with large vessel occlusions, over the time course of 10 to 14 weeks there is a higher additional benefit for prior thrombolysis treatment. Regarding that, both treatment arms show a similar outcome. A higher life quality regarding EQ5D is archived after direct EVT while judgement for general ability is rated higher with additional tPA treatment.
Conclusion: In this mono-center study it was shown that patients eligible for thrombolysis with large vessel occlusions should receive tPA if eligible. By lack or insufficient improvement, a rescue endovascular treatment should be applied. Direct endovascular treatment shows a similar outcome regarding mRS but a higher life quality index.
Stefan Mausbach*, Alexandra Gerasimova, Ze’ev Itsekson, Noit Brown, Yvonne Schwammenthal, Oleg Merzlyak, Mati Bakon and David Orion