title: Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke: A Pooled Analysis of the SWIFT and STAR Studies.
abstract: OBJECTIVE
  Mechanical thrombectomy (MT) improves clinical outcomes in patients with acute ischemic stroke (AIS) caused by a large vessel occlusion. However, it is not known whether intravenous thrombolysis (IVT) is of added benefit in patients undergoing MT.
  
  
  OBJECTIVE
  To examine whether treatment with IVT before MT with a stent retriever is beneficial in patients undergoing MT.
  
  
  METHODS
  This post hoc analysis used data from 291 patients treated with MT included in 2 large, multicenter, prospective clinical trials that evaluated MT for AIS (Solitaire With the Intention for Thrombectomy performed from January 1, 2010, through December 31, 2011, and Solitaire Flow Restoration Thrombectomy for Acute Revascularization from January 1, 2010, through December 31, 2012). An independent core laboratory scored the radiologic outcomes in each trial.
  
  
  METHODS
  Patients were treated with IVT with tissue plasminogen activator followed by MT (IVT and MT group) with the use of a stent retriever or MT with a stent retriever alone (MT group).
  
  
  METHODS
  Successful reperfusion, functional independence (modified Rankin Scale score of 0-2) and mortality at 90 days, symptomatic intracranial hemorrhage, emboli to new territory, and vasospasm were compared.
  
  
  RESULTS
  Of 291 patients included in the analysis, 160 (55.0%) underwent IVT and MT (mean [SD] age, 67 [13] years; 97 female [60.6%]), and 131 (45.0%) underwent MT alone (mean [SD] age, 69 [12] years; 71 [55.7%] female). Median Alberta Stroke Program Early CT Score at baseline was lower in the IVT and MT group (8 vs 9, P = .04). There was no statistically significant difference in the duration from symptom onset to groin puncture (254 minutes for the IVT and MT group vs 262 minutes for the MT group, P = .10). The number of passes, rate of successful reperfusion, functional independence at 90 days, mortality at 90 days, and emboli to new territory were also similar among groups. Symptomatic intracranial hemorrhage (1% vs 4%) and parenchymal hemorrhages type 1 (1% vs 3%) or type 2 (1% vs 2%) did not differ significantly (P = .25). Vasospasm occurred more often in patients who received IVT and MT vs MT alone (27% vs 14%, P = .006). In multivariate analysis, no statistically significant association was observed between IVT and MT vs MT alone for any of the outcomes.
  
  
  CONCLUSIONS
  The results indicate that treatment of patients experiencing AIS due to a large vessel occlusion with IVT before MT does not appear to provide a clinical benefit over MT alone. A randomized clinical trial seems warranted.
  
  
  BACKGROUND
  clinicaltrials.gov Identifiers: NCT01054560 and NCT01327989.
authors.affiliation: Department of Neurology, University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Coutinho
authors.affiliation: Neurovascular Imaging Research Core and the UCLA (University of California, Los Angeles) Stroke Center, Los Angeles.
authors.forename: David S
authors.initials: DS
authors.lastname: Liebeskind
authors.affiliation: Department of Radiology, Monash Health, Victoria, Australia.
authors.forename: Lee-Anne
authors.initials: LA
authors.lastname: Slater
authors.affiliation: Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Raul G
authors.initials: RG
authors.lastname: Nogueira
authors.affiliation: Department of Neurology, Oregon Health Science University, Portland.
authors.forename: Wayne
authors.initials: W
authors.lastname: Clark
authors.affiliation: Department of Neurosciences, Hospital Germans Trias I Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Antoni
authors.initials: A
authors.lastname: Dávalos
authors.affiliation: Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Bonafé
authors.affiliation: Division of Interventional Neuroradiology, UCLA.
authors.forename: Reza
authors.initials: R
authors.lastname: Jahan
authors.affiliation: Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
authors.forename: Urs
authors.initials: U
authors.lastname: Fischer
authors.affiliation: Departments of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
authors.forename: Jan
authors.initials: J
authors.lastname: Gralla
authors.affiliation: Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.affiliation: Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada13Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Vitor M
authors.initials: VM
authors.lastname: Pereira
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000000981:diagnostic imaging / Q000187:drug effects / Q000601:surgery; D002545:Brain Ischemia / Q000150:complications; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery*; D017131:Thrombectomy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator