Parallel Group, Randomized Clinical Trial of Direct Intra-arterial Thrombectomy Versus Intravenous Thrombolysis With Intra-arterial Thrombectomy for Patients With Large Vessel Occlusion of the Anterior Circulation
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 656
- 试验地点
- 1
- 主要终点
- mRS (the modified Rankin Scale)
研究概览
简要总结
Background: Intravenous thrombolysis (IVT) combined with mechanical thrombectomy (MT) has been proven safe and effective in patients with acute ischemic stroke (AIS) of anterior circulation large vessel occlusion (LVO). Despite recanalization, a considerable proportion of patients do not recover. The incidence of symptomatic intracerebral hemorrhage (sICH) was similar between combined IVT plus MT and IVT, suggesting that this complication could not be attributed to the MT, but rather to pre-treatment with IVT. Meanwhile, the incidence of intracranial atherosclerosis stenosis (ICAS) is higher in Asians. It is not clear whether patients with ICAS benefit from pretreatment with alteplase or not and how ICAS modifies treatment effect.
Objective: To assess whether direct MT is non-inferior compared to combined IVT plus MT in patients with AIS due to an anterior circulation LVO, and to assess treatment effect modification by presence of ICAD.
Study design: This is a parallel group, RCT of direct MT compared to combined IVT plus MT, using a non-inferiority design. The trial has observer blinded assessment of the primary outcome and of neuro-imaging at baseline and follow up. The trial will be executed in collaboration with MRCLEAN NO-IV investigators.
Study population: Patients with AIS of anterior circulation VLO confirmed by CTA. Initiation of IVT must be feasible within 4.5 hours from symptom onset. Age must be 18 or over and NIHSS 2 or more.
Main outcomes: The full distribution of the mRS at 3 months. Secondary outcomes: 1. death within 90 +/- 14 days; 2. pre-interventional reperfusion assessed on first intracranial DSA; 3. eTICI19 score on final angiography of MT; 4. score on the NIHSS at 24 +/- 6 hours and 5-7 days, or at discharge; 5. recanalization rate at 24-72h by CTA; 6. Final lesion volume at 5-7 days on NCCT20; 7. score on the EuroQoL 5-dimensions 5-level (EQ5D-5L)21 and Barthel index22 at 90 +/- 14 days; 8. dichotomous clinical outcome on the mRS at 90 +/- 14 days.
详细描述
Protocol title: Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: a Multicenter randomized clinical Trial (DIRECT-MT) Rationale: Mechanical thrombectomy (MT) by means of retrievable stents has been proven safe and effective in patients with acute ischemic stroke (AIS) with confirmed large vessel occlusion of the anterior circulation and in whom the procedure can be started within 6 hours from onset. Despite recanalization, a considerable proportion of patients do not recover. This can be attributed to potential adverse effects of the intravenous treatment (IVT) prior to MT. These effects could include neurotoxicity, blood brain barrier leakage and thrombus fragmentation through softening of the thrombus.
Another reason for non-recovery in MRCLEAN was the occurrence of symptomatic intracranial hemorrhage (sICH) in 7% of patients, which was fatal in 65%. sICH occurred as often in the intervention as in the control group, suggesting that this complication could not be attributed to the MT, but rather to pre-treatment with IVT. Therefore, the investigators hypothesize that direct MT may lead to a 8% absolute increase in good outcome compared to MT preceded by IVT.
Objective: To assess whether direct MT is non-inferior compared to combined IVT plus MT in patients with AIS due to an anterior circulation LVO, and to assess treatment effect modification by presence of ICAD.
Study design: This is a multicenter, prospective, open label parallel group trial with blinded outcome assessment (PROBE design) assessing non-inferiority of direct MT compared to combined IVT plus MT.
Study population: Patients with acute ischemic stroke and a confirmed anterior circulation occlusion by CTA. Initiation of IVT must be feasible within 4.5 hours from symptom onset. Age must be 18 or over and NIHSS 2 or more.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- Single (Outcomes Assessor)
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •a clinical diagnosis of acute ischemic stroke,
- •caused by a large vessel occlusion of the anterior circulation (distal intracranial carotid artery or middle M1/proximal M2) cerebral artery confirmed by CTA,
- •CT or MRI ruling out intracranial hemorrhage,
- •eligible for IVT and IAT (within 4.5 hours after symptom onset),
- •a score of at least 2 on the NIH Stroke Scale,
- •age of 18 years or older,
- •written informed consent.
排除标准
- •- Pre-stroke disability which interferes with the assessment of functional outcome at 90 days, i.e. mRS >2
- •Any contra-indication for IVT, according to guidelines of the American Heart Association, i.e.:
- •arterial blood pressure exceeding 185/110 mmHg
- •blood glucose less than 2.7 or over 22.2 mmol/L
- •cerebral infarction in the previous 6 weeks with residual neurological deficit or signs of recent infarction on neuro-imaging
- •serious head trauma in the previous 3 months
- •major surgery or serious trauma in the previous 2 weeks
- •gastrointestinal or urinary tract hemorrhage in the previous 3 weeks
- •previous intracerebral hemorrhage
- •use of anticoagulant with INR exceeding 1.7
- •known thrombocyte count less than 100 x 109/L
- •treatment with direct thrombin or factor X inhibitors
- •treatment with heparin (APTT exceeds the upper limit of normal value) in the previous 48 hours.
研究组 & 干预措施
Direct MT
Direct mechanical thrombectomy (MT) with no intravenous thrombolysis
干预措施: intra-arterial thrombectomy (Procedure)
IVT combine with MT
Intravenous thrombolysis before mechanical thrombectomy
干预措施: intra-arterial thrombectomy (Procedure)
IVT combine with MT
Intravenous thrombolysis before mechanical thrombectomy
干预措施: Intravenous thrombolysis (Drug)
结局指标
主要结局
mRS (the modified Rankin Scale)
时间窗: 3 months after procedure
The mRS is an ordinal hierarchical scale ranging from 0 to 5, with higher scores indicating more severe disability.
次要结局
- eTICI score (Extended Treatment In Cerebral Ischemia)(Immediately after procedure)
- Final infarct volume(at 5-7 days)
- sICH (symptomatic intracranial hemorrhage) rate(7 days after intra-arterial thrombectomy)
- NIHSS (The National Institutes of Health Stroke Scale)(at 24 hours and 5-7 days)
- Recanalization rate(at 24-48 hours after intra-arterial thrombectomy)
研究者
Jian-min Liu
Dean of the department of Neurosurgery
Changhai Hospital