Intra-arterial Thrombolysis After Successful Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion in the Posterior Circulation (IAT-TOP)
Overview
- Phase
- Not Applicable
- Intervention
- intra-arterial alteplase
- Conditions
- Acute Ischemic Stroke
- Sponsor
- Xuanwu Hospital, Beijing
- Enrollment
- 247
- Locations
- 1
- Primary Endpoint
- Rate of modified Rankin Scale (mRS) score of 0-2
- Status
- Completed
- Last Updated
- 8 months ago
Overview
Brief Summary
The CHOICE study suggested that the use of adjunct intra-arterial alteplase after successful endovascular reperfusion in large vessel occlusion acute ischemic strokes may result in a greater likelihood of excellent neurological outcome at 90 days. However, CHOICE was a phase-2 trial and almost exclusively enrolled anterior circulation occlusions. Therefore, data on the safety and efficacy of post-endovascular reperfusion IAT in posterior circulation stroke is lacking.
In general, anterior circulation strokes are associated with a higher risk of ICH than posterior circulation strokes. Therefore, we believe it might be safer to perform post-endovascular reperfusion IAT posterior circulation stroke. Also, there are more perforator artery in the posterior circulation, IAT would be more likely to show its benefit. Therefore, we would like to explore IA rt-PA for posterior circulation stroke after successful MT in our RCT.
In this study, one interim analysis will be performed when the enrollment volume reaches 50% of the total sample size (188 cases). DSMB will determine the premature termination or continuity of research.
Investigators
Eligibility Criteria
Inclusion Criteria
- •Symptoms and signs compatible with ischemia in the posterior circulation;
- •Basilar artery occlusion or vertebral artery occlusion without antegrade flow to the basilar artery confirmed by computed tomographic angiography (CTA)/ magnetic resonance angiography (MRA)/ digital subtraction angiography (DSA);
- •Age ≥18 years and ≤80 years;
- •Premorbid mRS ≤1;
- •National Institutes of Health Stroke Score (NIHSS) ≥6 at admission；
- •PC-ASPECTS on CT/CTA-Source Images/MRI-DWI 6-10；
- •Treated with endovascular thrombectomy (EVT) resulting in an eTICI score ≥2b50 at end of the procedure；
- •Time from symptom onset to randomization\<24 hours, including wake-up stroke and unwitnessed stroke; Time of onset of symptoms is defined as "last known well" (LKW) if symptoms are not witnessed or time of estimated basilar artery occlusion (defined as the time of sudden onset of basilar artery stroke symptoms, with no consideration of any preceding minor prodromal symptoms, as adjudicated by two neurologists) if symptoms are witnessed;
- •Informed consent obtained from the patient or his/her legal representative.
Exclusion Criteria
- •Contraindication to Intravenous Thrombolysis (except time to treatment);
- •Complete clinical recovery in the angiography suite by end of MT procedure;
- •More than 3 passes of thrombectomy device;
- •Dissection of occluded artery or intraoperative bleeding on DSA after thrombectomy;
- •Patients in sedation and intubated patients could not be included if baseline NIHSS is not obtained by a neurologist or emergency physician prior to sedation or intubation;
- •Seizures at stroke onset which would preclude obtaining a baseline NIHSS;
- •Bilateral dilated pupils;
- •Severe contrast allergy or absolute contraindication to iodinated contrast;
- •Systolic pressure \>185 mmHg or diastolic pressure \>110 mmHg, and cannot be controlled by antihypertensive drugs;
- •Blood glucose \<50 mg/dl (2.8 mmol/L) or \>400 mg/dl (22.2 mmol/L);
Arms & Interventions
Successful mechanical thrombectomy plus intra-arterial alteplase group
For patients in the successful MT plus intra-arterial alteplase group, after successful recanalization, neurointerventionalists administered intra-arterial thrombolysis with alteplase according to protocol. The angiographic scores will be assessed after intra-arterial thrombolysis.
Intervention: intra-arterial alteplase
Outcomes
Primary Outcomes
Rate of modified Rankin Scale (mRS) score of 0-2
Time Frame: 90 days (±7 days) after randomization
The mRS score range from 0 (no disability) to 6 (death)
Secondary Outcomes
- Rate of early neurological improvement(48 hours (±12 hours) after randomization)
- Change of eTICI(Before intra-arterial thrombolysis vs. immediately after the completion of intra-arterial thrombolysis)
- Improvement of the NIHSS score(7 days (±1 days) after randomization or discharge)
- Rate of mRS score of 0-3(90 days (±7 days) after randomization)
- All-cause mortality(90 days (±7 days) after randomization)
- Rate of symptomatic intracranial hemorrhage (sICH)(Within 48 hours after randomization)
- Proportional distribution of modified Rankin Score(90 days (±7 days) after randomization)
- Improvement of the National Institutes of Health Stroke Scale (NIHSS) score(48 hours (±12 hours) after randomization)
- EQ-5D-5L(90 days (±7 days) after randomization)
- Barthel Index(90 days (±7 days) after randomization)