Prior thrombolysis improves outcomes for M2 occlusion stroke patients undergoing thrombectomy

Gaultier Marnat

Intravenous thrombolysis (IVT) prior to a mechanical thrombectomy procedure could result in better functional outcomes than thrombectomy alone in stroke patients with M2 occlusions, as per a retrospective analysis derived from the Endovascular Treatment in Ischemic Stroke (ETIS) registry.

Outlining these findings in the Journal of NeuroInterventional Surgery (JNIS), a research team including corresponding author Gaultier Marnat (Centre Hospitalier Universitaire [CHU] de Bordeaux, Bordeaux, France) notes that—alongside the fact that IVT was not associated with an increased rate of haemorrhagic or procedural complications—their results suggest a benefit of IVT in M2 occlusion patients undergoing a thrombectomy procedure.

The authors initially posit that IVT in patients treated with mechanical thrombectomy for proximal occlusions has “recently been questioned” through randomised trials. However, they continue, few patients with M2 segment occlusions—which are somewhat controversial, as their categorisation as ‘proximal’ or ‘distal’ is subject to continued debate—were included in these trials.

As such, Marnat and colleagues set out to investigate the influence of prior IVT for patients presenting with M2 occlusions treated with mechanical thrombectomy, as compared to thrombectomy alone, via a retrospective analysis of the multicentre, observational ETIS registry. The ETIS registry includes prospective data from 29 of the 38 thrombectomy-capable centres in France, and more than 15,000 real-world stroke patients.

Writing in JNIS, Marnat and colleagues report that data from consecutive patients treated with thrombectomy for M2 occlusions between January 2015 and January 2022 at a total of 26 comprehensive stroke centres were analysed. The primary endpoint of their analysis was a 90-day modified Rankin Scale (mRS) score of 0–2. Outcomes were compared using propensity score approaches, and sensitivity analyses were performed in relevant patient subgroups, they add.

Among 1,132 patients with M2 occlusions treated with mechanical thrombectomy, 570 received prior IVT—leaving 562 who did not receive prior IVT, with the two groups being comparable after a propensity analysis.

The rate of favourable functional outcome was “significantly higher” in the IVT-plus-thrombectomy group (59.8%) compared with the thrombectomy-alone group (44.7%). In addition, haemorrhagic and procedural complications were similar in both groups. And, in a sensitivity analysis excluding patients with anticoagulation treatment, favourable recanalisation was more frequent in the IVT-plus-thrombectomy group.

Additional sensitivity analyses that focused on ‘mothership’ patients, and patients treated within 4.5 hours from symptom onset, also revealed similar safety and efficacy profiles associated with IVT prior to thrombectomy.

Marnat and colleagues therefore conclude that, in cases of M2 occlusions, prior IVT combined with mechanical thrombectomy resulted in better functional outcomes than thrombectomy alone, without increasing the rate of haemorrhagic or procedural complications.


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