Intravenous alteplase has different effects on the efficacy of aspiration and stent retriever thrombectomy: analysis of the COMPASS trial

Maxim Mokin, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, USA mokin@usf.edu.
Muhammad Waqas, Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
Johanna T. Fifi, Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Reade De Leacy, Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
David Fiorella, Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.
Elad I. Levy, Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
Kenneth Snyder, Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
Ricardo A. Hanel, Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA.
Keith Woodward, Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA.
Imran Chaudry, Neurosurgery, Prisma Health Upstate, Greenville, South Carolina, USA.
Ansaar T. Rai, Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA.
Donald Frei, Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA.
Josser E. Delgado Almandoz, Neurointerventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
Michael Kelly, Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Adam S. Arthur, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
Blaise W. Baxter MD, Lehigh Valley Health NetworkFollow
Joey English, Neurology and Radiology, University of California San Francisco (UCSF), San Francisco, California, USA.
Italo Linfante, Baptist Cardiac and Vascular Institute, Miami, Florida, USA.
Kyle M. Fargen, Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA.
Aquilla Turk, Neurosurgery, Prisma Health Upstate, Greenville, South Carolina, USA.

Document Type

Article

Publication Date

10-14-2021

Publication Title

Journal of neurointerventional surgery

E-ISSN

1759-8486

Department(s)

Department of Radiology and Diagnostic Medical Imaging

Keywords

brain, stent, stroke, thrombectomy, thrombolysis

Abstract

BACKGROUND: There is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT). METHODS: This was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration. RESULTS: In the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0-2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0). CONCLUSIONS: Prior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.

DOI

10.1136/neurintsurg-2021-017943

PubMed ID

34649935

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