Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial

Adnan Mujanovic; Omer Eker; Gaultier Marnat; Daniel Strbian; Petra Ijäs; Cécile Préterre; Aude Triquenot; Jean François Albucher; Maxime Gauberti; David Weisenburger-Lile; Marielle Ernst; Omid Nikoubashman; Anastasios Mpotsaris; Benjamin Gory; Vi Tuan Hua; Marc Ribo; David S Liebeskind; Tomas Dobrocky; Thomas R Meinel; Lukas Buetikofer; Jan Gralla; Urs Fischer; Johannes Kaesmacher; SWIFT DIRECT investigators

doi:10.1136/jnis-2022-019585

Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial

J Neurointerv Surg. 2023 Nov;15(e2):e232-e239. doi: 10.1136/jnis-2022-019585. Epub 2022 Nov 17.

Authors

Adnan Mujanovic¹, Omer Eker², Gaultier Marnat³, Daniel Strbian⁴, Petra Ijäs⁴, Cécile Préterre⁵, Aude Triquenot⁶, Jean François Albucher⁷, Maxime Gauberti⁸, David Weisenburger-Lile⁹, Marielle Ernst¹⁰, Omid Nikoubashman¹¹, Anastasios Mpotsaris¹², Benjamin Gory¹³, Vi Tuan Hua¹⁴, Marc Ribo¹⁵, David S Liebeskind¹⁶, Tomas Dobrocky¹, Thomas R Meinel¹⁷, Lukas Buetikofer¹⁸, Jan Gralla¹, Urs Fischer^#^{17

19}, Johannes Kaesmacher^#²⁰; SWIFT DIRECT investigators

Affiliations

¹ University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland.
² Department of Neuroradiology, Hospices Civils de Lyon, Bron, France.
³ Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France.
⁴ Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland.
⁵ Stroke Unit, University Hospital Centre Nantes, Nantes, France.
⁶ Department of Neurology, University Hospital Centre Rouen, Rouen, France.
⁷ Neurology, University Hospital Centre Toulouse, Toulouse, France.
⁸ Department of Neuroradiology, University Hospital Centre Caen, Caen, France.
⁹ Department of Stroke and Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France.
¹⁰ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Gottingen, Germany.
¹¹ Neuroradiology, University Hospital Aachen, Aachen, Germany.
¹² Department of Neuroradiology, München Klinik Harlaching, Munchen, Germany.
¹³ Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, France.
¹⁴ Department of Neurology, University Hospital Centre Reims, Reims, France.
¹⁵ Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain.
¹⁶ Department of Neurology, University of California Los Angeles, Los Angeles, California, USA.
¹⁷ Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland.
¹⁸ CTU Bern, University of Bern, Bern, Switzerland.
¹⁹ Department of Neurology, University Hospital Basel, Basel, Switzerland.
²⁰ University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland johannes.kaesmacher@insel.ch.

^# Contributed equally.

Abstract

Background: A potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there are few data on the occurrence of pre-interventional reperfusion in patients randomized to IVT or no IVT before MT.

Methods: SWIFT DIRECT (Solitaire With the Intention For Thrombectomy Plus Intravenous t-PA vs DIRECT Solitaire Stent-retriever Thrombectomy in Acute Anterior Circulation Stroke) was a randomized controlled trial including acute ischemic stroke IVT eligible patients being directly admitted to a comprehensive stroke center, with allocation to IVT with MT versus MT alone. The primary endpoint of this analysis was the occurrence of pre-interventional reperfusion, defined as a pre-interventional expanded Thrombolysis in Cerebral Infarction score of ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses.

Results: Of 396 patients, pre-interventional reperfusion occurred in 20 (10.0%) patients randomized to IVT with MT, and in 7 (3.6%) patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (adjusted OR 2.91, 95% CI 1.23 to 6.87). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture time (p for interaction=0.33), although the effect tended to be stronger in patients with a Randomization-to-Groin-Puncture time >28 min (adjusted OR 4.65, 95% CI 1.16 to 18.68). There were no significant differences in rates of functional outcomes between patients with and without pre-interventional reperfusion.

Conclusion: Even for patients with proximal large vessel occlusions and direct access to MT, IVT resulted in an absolute increase of 6% in rates of pre-interventional reperfusion. The influence of time strata on the occurrence of pre-interventional reperfusion should be studied further in an individual patient data meta-analysis of comparable trials.

Trial registration number: clinicaltrials.gov NCT03192332.

Keywords: Stroke; Thrombectomy; Thrombolysis.

Publication types

Meta-Analysis

MeSH terms

Brain Ischemia* / diagnostic imaging
Brain Ischemia* / drug therapy
Brain Ischemia* / surgery
Fibrinolytic Agents / therapeutic use
Humans
Ischemic Stroke* / etiology
Mechanical Thrombolysis* / methods
Randomized Controlled Trials as Topic
Reperfusion
Stroke* / diagnostic imaging
Stroke* / drug therapy
Stroke* / surgery
Thrombectomy / methods
Thrombolytic Therapy / methods
Treatment Outcome

Substances

Fibrinolytic Agents

Associated data

ClinicalTrials.gov/NCT03192332