Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke

Jeffrey Saver (1) , Mayank Goyal , Alain Bonafe (2, 3) , Hans-Christoph Diener , Elad Levy , Vitor Pereira , Gregory Albers , Christophe Cognard (4) , David Cohen , Werner Hacke , Olav Jansen , Tudor Jovin , Heinrich Mattle , Raul Nogueira , Adnan Siddiqui , Dileep Yavagal , Blaise Baxter , Thomas Devlin , Demetrius Lopes , Vivek Reddy , Richard Du Mesnil de Rochemont , Oliver Singer , Reza Jahan

1 UCLA - University of California [Los Angeles]
2 Département de Neuroradiologie[Montpellier]
3 INM - Institut des Neurosciences de Montpellier
4 CHU Toulouse - Centre Hospitalier Universitaire de Toulouse

BACKGROUND: Among patients with acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, less than 40% regain functional independence when treated with intravenous tissue plasminogen activator (t-PA) alone. Thrombectomy with the use of a stent retriever, in addition to intravenous t-PA, increases reperfusion rates and may improve long-term functional outcome. METHODS: We randomly assigned eligible patients with stroke who were receiving or had received intravenous t-PA to continue with t-PA alone (control group) or to undergo endovascular thrombectomy with the use of a stent retriever within 6 hours after symptom onset (intervention group). Patients had confirmed occlusions in the proximal anterior intracranial circulation and an absence of large ischemic-core lesions. The primary outcome was the severity of global disability at 90 days, as assessed by means of the modified Rankin scale (with scores ranging from 0 [no symptoms] to 6 [death]). RESULTS: The study was stopped early because of efficacy. At 39 centers, 196 patients underwent randomization (98 patients in each group). In the intervention group, the median time from qualifying imaging to groin puncture was 57 minutes, and the rate of substantial reperfusion at the end of the procedure was 88%. Thrombectomy with the stent retriever plus intravenous t-PA reduced disability at 90 days over the entire range of scores on the modified Rankin scale (P<0.001). The rate of functional independence (modified Rankin scale score, 0 to 2) was higher in the intervention group than in the control group (60% vs. 35%, P<0.001). There were no significant between-group differences in 90-day mortality (9% vs. 12%, P=0.50) or symptomatic intracranial hemorrhage (0% vs. 3%, P=0.12). CONCLUSIONS: In patients receiving intravenous t-PA for acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, thrombectomy with a stent retriever within 6 hours after onset improved functional outcomes at 90 days.

Domaines: Cardiologie et système cardiovasculaire

Jeffrey Saver, Mayank Goyal, Alain Bonafe, Hans-Christoph Diener, Elad Levy, et al.. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. New England Journal of Medicine, 2015, 372 (24), pp.2285-2295. ⟨10.1056/NEJMoa1415061⟩. ⟨hal-02007226⟩