Intra-arterial Treatment

The studies of IV fibrinolysis differ from the presented studies in particular with regard to the lacking confirmation of an occluded cerebral artery and the lesser degree of severity of the stroke. In such patients, the effect of fibrinolysis upon recanalization rate and treatment result of intra-arterial therapy (IAT) has yet to be determined.

In the ESCAPE study (1), recanalization rates of IAT with and without fibrinolysis did not significantly differ from one another (71% versus 77%; odds ratio 0.70; 95% confidence interval [0.31; 1.59]).

The metaanalysis of the ESCAPE and REVASCAT (2) study data indicates neither a significant difference in the treatment result of IAT with and without fibrinolysis (49% vs 51%; OR: 0.92; 95%-CI: [0.54; 1.56]) nor between IAT with and without fibrinolysis and the respective control groups (absolute risk reduction [aRR] 20.1 percentage points; OR: 2.36; 95%-CI: [1.55; 3.60] versus aRR 23.5 percentage points; OR: 2.74; 95%-CI: [1.30; 5.75]). Whether other factors affect these results is not obvious on the basis of the study data. However, patient selection including perfusion imaging has an impact on the probability of favorable prognosis rather than the effect of treatment (3).

In large thrombus volumes the therapeutic benefit of IAT may be explained by the effect of mechanical vascular recanalization and not by the effect of fibrinolysis. For this reason, IAT extends the therapeutic spectrum – rather than complementing it – to a group of patients in whom intravenous fibrinolysis obviously does not have a significant therapeutic effect and can therefore not be described as standard therapy. Withholding IAT from a patient without prior fibrinolysis can definitely not be justified in view of what is currently known.