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WSC 2022 | Mechanical thrombectomy with or without thrombolysis: reviewing the evidence

Adnan Qureshi, MD, University of Missouri-Columbia, Columbia, MO, shares his thoughts on the era-defining question in stroke care: mechanical thrombectomy (MT) with or without prior intravenous thrombolysis (IVT)? For eligible patients with a large vessel occlusion (LVO) ischemic stroke presenting within 4.5 hours of symptom onset, IVT bridging therapy is recognized as the gold standard. However, questions have arisen over recent years on whether IVT provides any additional benefit beyond what MT is capable of alone. The results of four large randomized clinical trials (SKIP, DEVT, DIRECT-MT, and MR CLEAN NO IV) have shown that there is no difference in the rates of functional independence achieved with both approaches. In a MT-capable center therefore, there may not be a need for IVT prior to MT. However, the systems of care in many regions mean that patients do not have access to a comprehensive stroke center or may be first taken to a local facility and later transferred. In this scenario, it may be the case that IVT followed by rapid transfer is better than simply delaying all treatment. The growing use of tenecteplase in place of alteplase must also be considered, as this third-generation thrombolytic may perform differently to alteplase. The recent DIRECT-SAFE trial (NCT03494920) of direct MT versus standard bridging therapy included patients who received tenecteplase in the IVT arm. In this trial, the IVT group did better than those receiving MT alone. Dr Qureshi also notes the limitations of the non-inferiority trials conducted to date, which by design would have needed a very large difference between the two arms to conclude that they were not equivalent. This interview took place at the World Stroke Congress 2022 in Singapore.

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