title: Intra-arterial thrombectomy versus standard intravenous thrombolysis in patients with anterior circulation stroke caused by intracranial arterial occlusions: a single-center experience.
abstract: BACKGROUND
  Severely impaired patients with persisting intracranial occlusion despite standard treatment with intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA) or presenting beyond the therapeutic window for IV rtPA may be candidates for interventional neurothrombectomy (NT). The safety and efficacy of NT by the Penumbra System (PS) were compared with standard IV rtPA treatment in patients with severe acute ischemic stroke (AIS) caused by large intracranial vessel occlusion in the anterior circulation.
  
  
  METHODS
  Consecutive AIS patients underwent a predefined treatment algorithm based on arrival time, stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score, and site of arterial occlusion on computed tomographic angiography (CTA). NT was performed either after a standard dose of IV rtPA (bridging therapy [BT]) or as single treatment (stand-alone NT [SAT]). Rates of recanalization, symptomatic intracranial bleeding (SIB), mortality, and functional outcome in NT patients were compared with a historical cohort of IV rtPA treated patients (i.e., controls). Three-month favourable outcome was defined as a modified Rankin Scale (mRS) score ≤2.
  
  
  RESULTS
  Forty-six AIS patients were treated with NT and 51 with IV rtPA. The 2 groups did not differ with regard to demographics, onset NIHSS score (18.5±4 v 17±5; P=.06), or site of intracranial occlusion. Onset-to-treatment time in the NT and IV rtPA groups was 230 minutes (±78) and 176.5 (±44) minutes, respectively (P=.001). NT patients had significantly higher percentages of major improvement (≥8 points NIHSS score change at 24 hours; 26% v 10%; P=.03) and partial/complete recanalization (93.5% v 45%; P<.0001) compared to controls. Treatment by either SAT or BT similarly improved the chance of early recanalization and early clinical improvement. No significant differences were observed in the rate of SIB (11% v 6%), 3-month mortality (24% v 25%), or favorable outcome (40% v 35%) between NT and IV rtPA patients.
  
  
  CONCLUSIONS
  Despite significantly delayed time of intervention, NT patients had higher rates of recanalization and early major improvement, with no differences in symptomatic intracranial hemorrhages. Early NIHSS score improvement did not translate into better 3-month mortality or outcome. NT seems a safe and effective adjuvant treatment strategy for selected patients with severe AIS secondary to large intracranial vessel occlusion in the anterior circulation.
authors: Stroke Unit, Department of Neuroscience, University of Rome Tor Vergata, Rome, Italy; Fondazione Santa Lucia IRCCS, Rome, Italy. Electronic address: fabriziosallustio@libero.it.
authors: Fabrizio
authors: F
authors: Sallustio
authors: Giacomo
authors: G
authors: Koch
authors: Silvia
authors: S
authors: Di Legge
authors: Costanza
authors: C
authors: Rossi
authors: Barbara
authors: B
authors: Rizzato
authors: Simone
authors: S
authors: Napolitano
authors: Domenico
authors: D
authors: Samà
authors: Natale
authors: N
authors: Arnò
authors: Angela
authors: A
authors: Giordano
authors: Domenicantonio
authors: D
authors: Tropepi
authors: Giulia
authors: G
authors: Misaggi
authors: Marina
authors: M
authors: Diomedi
authors: Costantino
authors: C
authors: Del Giudice
authors: Alessio
authors: A
authors: Spinelli
authors: Sebastiano
authors: S
authors: Fabiano
authors: Matteo
authors: M
authors: Stefanini
authors: Daniel
authors: D
authors: Konda
authors: Carlo Andrea
authors: CA
authors: Reale
authors: Enrico
authors: E
authors: Pampana
authors: Giovanni
authors: G
authors: Simonetti
authors: Paolo
authors: P
authors: Stanzione
authors: Roberto
authors: R
authors: Gandini
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000503:physiopathology / Q000628:therapy*; D003131:Combined Modality Therapy; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D020243:Infarction, Anterior Cerebral Artery / Q000503:physiopathology / Q000628:therapy*; D020300:Intracranial Hemorrhages / Q000453:epidemiology / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D017131:Thrombectomy / Q000009:adverse effects / Q000379:methods*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Acute ischemic stroke; intravenous thrombolysis; large intracranial vessel occlusion; neurothrombectomy