ESOC 2024 | Effect of IVT on delayed reperfusion after incomplete mechanical thrombectomy
Adnan Mujanovic, MD, from Inselspital, Bern University Hospital, Switzerland, discusses new evidence regarding the effect of intravenous thrombolysis (IVT) on delayed reperfusion after incomplete mechanical thrombectomy. Knowing that 50% of patients treated with mechanical thrombectomy have incomplete reperfusion, the team wanted to look at the impact of IVT 24 hours after the intervention, rather than only assessing its immediate consequences. Data were included from multiple studies, showing that the use of IVT did have an impact on the occurrence of delayed reperfusion but notably, when stratified by choice of lytic, this effect was only preserved in groups administered tenecteplase. These patients showed increased rates of complete delayed reperfusion after 24 hours, which was associated with better functional outcomes at three months. It was also found that patients who were directly admitted to stroke centers had a better chance of complete spontaneous reperfusion than those transferred later. This interview took place at the 10th European Stroke Organisation Conference (ESOC) 2024 in Basel, Switzerland.
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Transcript
It’s actually a very interesting study because usually when we have these kind of studies the immediate effect of IVT is investigated, meaning that until the end of the procedure or until the end of the intervention you get this effect of IVT which is also the pathophysiological rationale behind it. That’s why kind of in the early trials but also nowadays almost all the effects of IVT are expected to happen in the early time window...
It’s actually a very interesting study because usually when we have these kind of studies the immediate effect of IVT is investigated, meaning that until the end of the procedure or until the end of the intervention you get this effect of IVT which is also the pathophysiological rationale behind it. That’s why kind of in the early trials but also nowadays almost all the effects of IVT are expected to happen in the early time window.
We had an idea if there is this exposure to IVT, so if the patient does receive IVT, will it have any consequences in the long term and when I say long term I mean 24 hours. So after the intervention, after everything is finalized, while the patient is still in the hospital at 24 hours, will there be any effect? For example, because 50% of EVT treated patients have incomplete reperfusion. So is there this effect of IVT among these patients who have incomplete reperfusion?
So we took a look at the data and basically what we saw is that there is an effect of IVT in the case of incomplete reperfusion, from eTICI 2A to eTICI 2C, that is what is being defined as incomplete reperfusion. We pulled the data from several randomized trials, from a prospective registry in Austria, from our hospital in Bern, so we also stratified the data on alteplase and tenecteplase because both of these lytics were used across these trials and we also used the EXTEND-IA and EXTEND-IA TNK data which used tenecteplase. When we stratify the data on the alteplase and tenecteplase, we saw that this actual effect was only preserved in the tenecteplase group. For patients who have received tenecteplase and who do experience incomplete reperfusion, at 24 hours they would have spontaneous complete delayed reperfusion which is associated significantly with better functional outcomes at 3 months, at 24 hours, etc… So we saw this beneficial effect of tenecteplase and we were really excited about it because we were kind of the first who looked at the long-term effects of tenecteplase, so not the immediate intervention one but also the 24-hour and how does this impact the patients. This is really relevant because as I have stated at the beginning, 50% of patients who are treated with thrombectomy end up with incomplete reperfusion which is the cohort which we investigated.
We also took a look at some timing values, like if the timing makes a difference and of course it does because it’s also related to the pharmacological efficiency of the lytics and how do they work. We saw that those patients who are directly admitted to the treating stroke center have a benefit of this lytic to complete spontaneous delayed reperfusion, while in patients who are transferred, because of the longer time delays which you need from transferring from the primary to the comprehensive stroke center, they couldn’t see this effect. So those were really interesting findings and we were actually really happy to share them because as I said we were kind of the first ones who were looking at the 24-hour effect of tenecteplase after incomplete reperfusion.
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