Neurology: For mild strokes, the combined treatment of thrombolysis and thrombus removal is more effective

Vessels within the thrombus resection (the EVT) is the treatment of acute ischemic stroke large vessel occlusion standard treatment (the LVO) patients before the proximal end of the cycle (AIS), significant improvement because it is closely related to improving function and survival of .

Although in key EVT trials, more than 80% of participants received intravenous alteplase (tPA) before EVT, and current international recommendations advocate intravenous thrombolysis for all eligible patients with LVO before starting EVT (IVT) (Recommendation Level I, Level of Evidence), but people are concerned about the utility of tPA pretreatment for LVO patients who choose EVT.

Views in support of direct EVT (dEVT) include: TPA pretreatment may delay the initiation of EVT, low overall recanalization rate of intravenous tPA before thrombectomy, increased fragility and migration of thrombus, increased risk of distal emboli, combined therapy (bridging therapy) , BT: IVT plus EVT) increased risk of systemic and bleeding complications, and increased TPA management costs.

After the publication of the observational registration data, the effectiveness of IVT pretreatment has been further questioned.
These data show that LVO patients bypass primary stroke centers that can only initiate tPA treatment and go directly to stroke centers with EVT capabilities.
The results are even more serious.
it is good.

On the other hand, the views that support intravenous thrombolysis before EVT are: early reperfusion potential is observed in 7-8% of early window EVT test patients, thrombus softening and promotion of successful reperfusion, intravenous tPA cannot be successful in EVT The potential role in patients with reperfusion and the impact on distal residual occlusion after EVT.

In addition, the potential benefits of IVT may not occur in all patients receiving EVT, but are specific to certain subgroups.
This is related to the severity of stroke at the onset of the patient, and is also related to whether IVT is performed in a non-EVT center or directly It is related to entering a center with EVT capability.

The SELECT (Optimization of Patient Selection for Endovascular Treatment of Acute Ischemic Stroke) study aims to investigate the difference between the safety and effectiveness of dEVT and BT in AIS patients with anterior circulation LVO within 4.
5 hours.
And to evaluate whether the potential effect of BT treatment is affected by the following factors: the severity of stroke, the size of the ischemic core, and the status of reporting to centers with EVT capabilities (direct transfer and second transfer).

They included 226 LVO (54%: male, mean age: 65.
6±14.
6 years, median NIHSS score: 17, 28% received DEVT).

The median time from arrival at the hospital to inguinal puncture for BT patients is [dEVT: 1.
43 (IQR=1.
13-1.
90) hours vs.
BT: 1.
58 (IQR=1.
27-2.
02) hours, p=0.
40] or transferred to a doctor.
The center of EVT capability [dEVT: 1.
17 (IQR: 0.
90-1.
48) hours vs.
BT: 1.
27 (IQR: 0.
97-1.
87) hours, p=0.
24], there is no difference.

BT is associated with higher 90-day functional independence and functional improvement, and a lower probability of death at 90 days.

In the subgroup analysis, compared with dEVT, BT patients with a baseline NIHSS score of <15 had a higher probability of functional independence; for patients with an NIHSS score of ≥15, this association was not obvious.

Among patients stratified by infarct volume, the subgroup with ischemic core <50cc and the subgroup who were transferred to the hospital, the functional outcome of BT improved significantly.

.

The important significance of this study is that it is found that for patients with a lighter NIHSS score, a smaller infarct core volume, and patients transferred for treatment, the combination therapy has better clinical results .