title: Rescue Thrombectomy in Large Vessel Occlusion Strokes Leads to Better Outcomes than Intravenous Thrombolysis Alone: A 'Real World' Applicability of the Recent Trials.
abstract: BACKGROUND
  The Interventional Management of Stroke III (IMS-III) trial demonstrated no benefit for intravenous recombinant tissue plasminogen activator (IV rt-PA) followed by endovascular therapy versus IV rt-PA alone. However, IMS-III mostly included earlier generation devices. The recent thrombectomy trials have incorporated the stent-retriever technology, but their generalizability remains unknown.
  
  
  METHODS
  The North American Solitaire Acute Stroke (NASA) registry recruited patients treated with the Solitaire FR™ device between March 2012 and February 2013. The NASA-IMS-III-Like Group (NILG baseline NIHSS score ≥10 who received IV rt-PA) was compared to the IV rt-PA and IV + intra-arterial (IA)-IMS-III groups and the MR CLEAN, ESCAPE, SWIFT Prime, and REVASCAT trial controls to assess the stent-retriever treatment in the 'real-world' setting. The NILG was also compared to non-IV rt-PA NASA patients to evaluate the impact of IV rt-PA on thrombectomy.
  
  
  RESULTS
  A total of 136 of the 354 NASA patients fulfilled criteria for the NILG. Baseline characteristics were well balanced across groups. Time from onset to puncture was higher in NILG than IV+IA-IMS-III patients (274 ± 112 vs. 208 ± 47 min, p < 0.0001). Occlusions involving the intracranial ICA, MCA-M1, or basilar arteries were more common in NILG than IV+IA-IMS-III patients (91.2 vs. 47.2%, p < 0.00001). Modified thrombolysis in cerebral infarction ≥2b reperfusion was higher in NILG than IV+IA-IMS-III patients (74.3 vs. 39.6%, p < 0.00001). A 90-day modified Rankin Scale score ≤2 was more frequent in the NILG than IV+IA-IMS-III patients (51.9 vs. 40.8%, p = 0.03) and MR CLEAN (51.9 vs. 19.1%, p < 0.00001), ESCAPE (51.9 vs. 29.3%, p = 0.0002), SWIFT Prime (51.9 vs. 35.5%, p = 0.02), and REVASCAT (51.9 vs. 28.2%, p = 0.0003) controls. Symptomatic intracranial hemorrhage definitions varied across the different studies with rates ranging from 2.7% (ESCAPE) to 11.9% (NILG). The NILG 90-day mortality (24.4%) was higher than in SWIFT Prime but comparable to all other groups. IV rt-PA was an independent predictor of good outcome in NASA (OR = 2.3, 95% CI 1.2-4.7).
  
  
  CONCLUSIONS
  Our results support the 'real-world' applicability of the recent thrombectomy trials.
authors: Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA.
authors: Raul G
authors: RG
authors: Nogueira
authors: Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA.
authors: Osama O
authors: OO
authors: Zaidat
authors: Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA.
authors: Alicia C
authors: AC
authors: Castonguay
authors: Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA.
authors: Diogo C
authors: DC
authors: Haussen
authors: St. Luke's Neuroscience Institute, Kansas City, Mo., USA.
authors: Coleman O
authors: CO
authors: Martin
authors: St. Luke's Neuroscience Institute, Kansas City, Mo., USA.
authors: William E
authors: WE
authors: Holloway
authors: Department of Neurology, Delray Medical Center, Delray Beach, Fla., USA.
authors: Nils
authors: N
authors: Mueller-Kronast
authors: California Pacific Medical Center, San Francisco, Calif., USA.
authors: Joey
authors: J
authors: English
authors: Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Fla., USA.
authors: Italo
authors: I
authors: Linfante
authors: Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Fla., USA.
authors: Guilherme
authors: G
authors: Dabus
authors: Alexian Brothers Medical Center, Elk Grove Village, Ill., USA.
authors: Tim W
authors: TW
authors: Malisch
authors: Alexian Brothers Medical Center, Elk Grove Village, Ill., USA.
authors: Franklin A
authors: FA
authors: Marden
authors: Oregon Health and Sciences, Portland, Oreg., USA.
authors: Hormozd
authors: H
authors: Bozorgchami
authors: Department of Neurology, Wayne State University School of Medicine, Detroit, Mich., USA.
authors: Andrew
authors: A
authors: Xavier
authors: Department of Radiology, West Virginia University Hospital, Morgantown, W.Va., USA.
authors: Ansaar T
authors: AT
authors: Rai
authors: Department of Neurology, Neurosurgery, and Radiology, Vanderbilt University Medical Center, Nashville, Tenn., USA.
authors: Michael T
authors: MT
authors: Froehler
authors: Department of Neurosurgery, Presence Saint Joseph Medical Center, Joliet, Ill., USA.
authors: Aamir
authors: A
authors: Badruddin
authors: Department of Neurology, Boston University School of Medicine, Boston, Mass., USA.
authors: Thanh N
authors: TN
authors: Nguyen
authors: Desert Regional Medical Center, Palm Springs, Calif., USA.
authors: M Asif
authors: MA
authors: Taqi
authors: University of Kansas Medical Center, Kansas City, Kans., USA.
authors: Michael G
authors: MG
authors: Abraham
authors: Texas Stroke Institute, Dallas Fort-Worth Metroplex, Tex., USA.
authors: Vallabh
authors: V
authors: Janardhan
authors: Texas Stroke Institute, Dallas Fort-Worth Metroplex, Tex., USA.
authors: Albert J
authors: AJ
authors: Yoo
authors: Baylor College of Medicine, Houston, Tex., USA.
authors: Hashem
authors: H
authors: Shaltoni
authors: Department of Neurology, University of Louisville Medical School, Louisville, Ky., USA.
authors: Alex
authors: A
authors: Abou-Chebl
authors: Department of Neurosurgery, University of Texas, Houston, Tex., USA.
authors: Peng R
authors: PR
authors: Chen
authors: Department of Neurosurgery, Methodist Neurological Institute, Houston, Tex., USA.
authors: Gavin W
authors: GW
authors: Britz
authors: Department of Radiology and Neurology, UT Southwestern Medical Center, Dallas, Tex., USA.
authors: Roberta
authors: R
authors: Novakovic
authors: University of Missouri, Columbia, Mo., USA.
authors: Ashish
authors: A
authors: Nanda
authors: Saint Louis University, St. Louis, Mo., USA.
authors: Ritesh
authors: R
authors: Kaushal
authors: Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA.
authors: Mohammad A
authors: MA
authors: Issa
authors: Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA.
authors: Michael R
authors: MR
authors: Frankel
authors: Department of Neurosurgery, Wellstar Medical Group, Marietta., USA.
authors: Rishi
authors: R
authors: Gupta
keywords: Interventional Management of Stroke III trial; Intravenous thrombolysis; Large vessel occlusion; Rescue thrombectomy