Intraarterial Thrombolysis as an Adjunct to Thrombectomy in Acute Ischemic Stroke: Current Status and Future Prospects

IF 2.3 4区医学 Q3 CLINICAL NEUROLOGY

Journal of Neuroimaging Pub Date : 2025-03-17 DOI:10.1111/jon.70030

Adnan I. Qureshi, Mohammed M. Al-Salihi, Ibrahim A. Bhatti, Maryam S. Al-Jebur, Ahmed Abd Elazim, Sameer A. Ansari, Daniel E. Ford, Daniel F. Hanley, Ameer E. Hassan, Pashmeen Lakhani, David R. Mehr, Thanh N. Nguyen, Alejandro M. Spiotta, William J. Powers, Syed F. Zaidi

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引用次数: 0

Abstract

Background and Purpose

Intraarterial thrombolysis (IAT) has been sporadically used as an adjunct to mechanical thrombectomy (MT) in acute ischemic stroke patients for nearly two decades to improve distal arterial and microvascular perfusion even in patients with near complete or complete recanalization.

Methods

We provide an overall narrative review that includes a systematic review and meta-analysis of two randomized controlled trials (RCTs), Chemical Optimization of Cerebral Embolectomy and Endovascular Recanalization in Patients with Acute Posterior Circulation Arterial Occlusion, to identify current and future implications. Risk ratios (RRs) were calculated from RCTs using a fixed-effects model. We identified 10 ongoing or planned RCTs after a search on clinicaltrials.gov and other sources, of which eight are in China, one in Europe, and one in Australia.

Results

A previous meta-analysis of 16 (predominantly observational) studies involving 7572 MT-treated patients had identified 14% higher odds of functional independence (modified Rankin scale [mRS] 0–2) at 90 days in patients treated with IAT. In the current analysis of 321 patients who underwent MT in RCTs, 165 were randomized to IAT and 156 were in the control group. The RR of achieving an mRS score of 0–1 at 90 days postrandomization was higher in patients treated with IAT compared with the control group (absolute increase of 12.87%, RR = 1.39, 95% confidence interval [CI] 1.04–1.86). The rate of symptomatic intracerebral hemorrhage (sICH) within 24 h was slightly higher (absolute increase of 1.64%, RR = 0.95, 95% CI 0.07–13.30) in patients treated with IAT. The ongoing RCTs have sample sizes ranging from 80 to 498 that can identify very large minimal clinically important differences (MCIDs) (13%–20% increase) in primary outcomes, but smaller MCIDs (<10%) that can still result in practice changes with interventions associated with low cost and complexity and are easy to implement, such as IAT, will not be identified.

Conclusions

Observational studies and recent RCTs suggest a potential benefit of IAT in improving functional outcomes among patients post-MT, although the potentially increased risk of sICH, inadequate sample sizes, and lack of data from the United States need to be considered. A large, definitive, and generalizable RCT is required to establish the therapeutic value and safety profile of IAT prior to widespread incorporation into routine practice.

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动脉内溶栓作为急性缺血性卒中取栓的辅助手段：现状和未来展望

近二十年来，动脉内溶栓（IAT）作为机械取栓（MT）的辅助手段在急性缺血性脑卒中患者中被零星地使用，以改善远端动脉和微血管灌注，即使是在几乎完全或完全再通的患者中也是如此。方法：我们对两项随机对照试验（RCTs）进行系统回顾和荟萃分析，即急性后循环动脉闭塞患者脑栓塞切除术和血管内再通的化学优化，以确定当前和未来的影响。使用固定效应模型从随机对照试验中计算风险比（rr）。通过检索clinicaltrials.gov和其他来源，我们确定了10项正在进行或计划进行的随机对照试验，其中8项在中国，1项在欧洲，1项在澳大利亚。先前的荟萃分析包括16项（主要是观察性）研究，涉及7572名mt治疗患者，发现IAT治疗患者90天功能独立性（修正Rankin量表[mRS] 0-2）的几率高出14%。在目前的分析中，321例接受MT的随机对照试验中，165例被随机分配到IAT组，156例被分配到对照组。与对照组相比，接受IAT治疗的患者在随机化后90天mRS评分为0-1的RR更高（绝对增加12.87%,RR = 1.39, 95%可信区间[CI] 1.04-1.86）。IAT组24 h内症状性脑出血（siich）发生率略高（绝对升高1.64%,RR = 0.95, 95% CI 0.07 ~ 13.30）。正在进行的随机对照试验的样本量从80到498不等，可以确定主要结局的非常大的最小临床重要差异（MCIDs）（增加13%-20%），但较小的MCIDs（10%）仍然可以导致实践变化，与低成本和复杂性相关的干预措施，如IAT，易于实施，将无法确定。结论：观察性研究和最近的随机对照试验表明，IAT在改善mt后患者的功能结局方面有潜在的益处，尽管需要考虑到潜在的sICH风险增加、样本量不足以及缺乏来自美国的数据。在广泛纳入常规实践之前，需要进行大规模、明确和可推广的随机对照试验来确定IAT的治疗价值和安全性。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of Neuroimaging 医学-核医学

CiteScore

4.70

自引率

0.00%

发文量

117

审稿时长

6-12 weeks

期刊介绍： Start reading the Journal of Neuroimaging to learn the latest neurological imaging techniques. The peer-reviewed research is written in a practical clinical context, giving you the information you need on: MRI CT Carotid Ultrasound and TCD SPECT PET Endovascular Surgical Neuroradiology Functional MRI Xenon CT and other new and upcoming neuroscientific modalities.The Journal of Neuroimaging addresses the full spectrum of human nervous system disease, including stroke, neoplasia, degenerating and demyelinating disease, epilepsy, tumors, lesions, infectious disease, cerebral vascular arterial diseases, toxic-metabolic disease, psychoses, dementias, heredo-familial disease, and trauma.Offering original research, review articles, case reports, neuroimaging CPCs, and evaluations of instruments and technology relevant to the nervous system, the Journal of Neuroimaging focuses on useful clinical developments and applications, tested techniques and interpretations, patient care, diagnostics, and therapeutics. Start reading today!