13 Jan tPA Plus Mechanical Thrombectomy in Acute Ischemic Stroke?
MedicalResearch.com Interview with:
Vitor Mendes Pereira MD MSc
Division of Neuroradiology – Joint Department of Medical Imaging
Division of Neurosurgery – Department of Surgery
Toronto Western Hospital – University Health Network
Associate Professor of Radiology and Surgery
University of Toronto
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Our study is a pooled analysis of two large prospective stroke studies that evaluated the effectiveness of mechanical thrombectomy (MT) using one of the stent retrievers (Solitaire device ) in patients with acute ischemic stroke related to large vessel occlusion(LVO). It is known (after 5 randomized controlled trials in 2015) that IV rtPA alone failed to demonstrated benefit when compared to MT associated or not to rtPA. A question is still open: what it is the real benefit of IV rtPA in the context of LVO, particularly in centres that can offer mechanical thrombectomy within 60 minutes after qualifying imaging?
MedicalResearch.com: What should readers take away from your report?
Response: In our study, we did not see a benefit or harm from IV rtPA in combination with mechanical thrombectomy however, our results should to be taken with caution. This is a post hoc analysis of the STAR and SWIFT studies in which the patients were not randomized for the use of rtPA in the context of MT. Patients undergone to MT alone had potentially a contraindication that might have affected their outcomes. We cared to perform multivariated analysis to address possible imbalances.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: To this date, there is no other multicenter prospective study databases that can address this issue similarly that was done in our study. Although these results are very interesting, our study is not the final word! A randomized controlled trial (RCT) is warranted. An international initiative started last year amongst centres in Europe and North America to perform such a RCT that will be called SWIFT DIRECT. This is an investigator initiated trial coordinated by two centres: Inselspital in Bern, Switzerland and Toronto Western Hospital in Canada. The objective will be to randomize 530 patients into two arm: MT alone and mechanical thrombectomy with rtPA. The stroke field particularly the acute treatment has been dramatically changing last few years. Many new questions have been raised now that we demonstrated the benefit of MT. The role of rtPA for patients with large vessel occlusion is the next big questions. The answer may have a safety and cost effectiveness impact on direct patient care and on stroke systems on regional and national levels worldwide.
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Coutinho JM, Liebeskind DS, Slater L, Nogueira RG, Clark W, Dávalos A, Bonafé A, Jahan R, Fischer U, Gralla J, Saver JL, Pereira VM. Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic StrokeA Pooled Analysis of the SWIFT and STAR Studies. JAMA Neurol. Published online January 09, 2017. doi:10.1001/jamaneurol.2016.5374
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