title: Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis.
abstract: OBJECTIVE
  Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear.
  
  
  METHODS
  We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2.
  
  
  RESULTS
  From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group.
  
  
  CONCLUSIONS
  In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Anne
authors.initials: A
authors.lastname: Broeg-Morvay
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Mordasini
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Corrado
authors.initials: C
authors.lastname: Bernasconi
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Monika
authors.initials: M
authors.lastname: Bühlmann
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Frauke
authors.initials: F
authors.lastname: Pult
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Marcel
authors.initials: M
authors.lastname: Arnold
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schroth
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Simon
authors.initials: S
authors.lastname: Jung
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Heinrich P
authors.initials: HP
authors.lastname: Mattle
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
authors.forename: Jan
authors.initials: J
authors.lastname: Gralla
authors.affiliation: From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland. urs.fischer@insel.ch.
authors.forename: Urs
authors.initials: U
authors.lastname: Fischer
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D017131:Thrombectomy / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: bridging thrombolysis; ischemic stroke; mechanical thrombolysis; thrombectomy; tissue-type plasminogen activator