Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke

RCT (n=656 in China) found endovascular thrombectomy (ET) noninferior to combined IV alteplase (within 4.5hrs symptoms) and ET in regard to primary outcome (OR 1.07; 95% CI, 0.81-1.40; p=0.04,noninferiority) within 20% margin of confidence, in patients with large-vessel occlusion

SPS commentary:

An editorial notes that although non-inferiority was established, the margin that was used to declare non-inferiority was generous, and the confidence intervals did not exclude a benefit of approximately 20% in the combination-therapy group. It alludes to a similar Japanese trial, which did not establish the non-inferiority of thrombectomy without alteplase pre-treatment to thrombectomy alone. It adds that recent trials suggest pretreatment with newer thrombolytic agents may be more effective than with alteplase. Furthermore, the mismatch between the high percentages of patients with reperfusion and the much smaller percentages of patients with clinical recovery in thrombectomy studies suggests that a substantial volume of brain tissue is already irreversibly injured in many patients by the time reperfusion occurs. It suggest that to improve outcomes in future stroke trials, adjunctive therapies, such as thrombolytic or neuroprotective agents, might be started early, at the primary stroke centre or in the prehospital setting. It concludes that until more data are available, it is appropriate to follow current guidelines that recommend all eligible patients receive alteplase before thrombectomy.


New England Journal of Medicine

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