Impact of Thrombus Length on Outcomes After Intra-Arterial Aspiration Thrombectomy in the THERAPY Trial

• Published in: Stroke (1970) Vol. 48; no. 7; pp. 1895 - 1900
• Main Authors: Yoo, Albert J, Khatri, Pooja, Mocco, J, Zaidat, Osama O, Gupta, Rishi, Frei, Donald, Lopes, Demetrius, Shownkeen, Harish, Berkhemer, Olvert A, Meyer, Denise, Hak, Susana S, Kuo, Sophia S, Buell, Hope, Bose, Arani, Sit, Siu Po, von Kummer, Rüdiger
• Format: Journal Article
• Language: English
• Published: United States American Heart Association, Inc 01.07.2017
• Subjects: Aged; Aged, 80 and over; Brain Ischemia - diagnostic imaging; Brain Ischemia - drug therapy; Brain Ischemia - surgery; Combined Modality Therapy; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - pharmacology; Follow-Up Studies; Humans; Intracranial Thrombosis - diagnostic imaging; Intracranial Thrombosis - drug therapy; Intracranial Thrombosis - surgery; Male; Middle Aged; Outcome Assessment (Health Care); Stroke - diagnostic imaging; Stroke - drug therapy; Stroke - surgery; Thrombectomy - methods; Time Factors; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - pharmacology; thrombosis; stroke; thrombectomy; middle cerebral artery
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/STROKEAHA.116.016253

BACKGROUND AND PURPOSE—Increasing thrombus length (TL) impedes recanalization after intravenous (IV) thrombolysis. We sought to determine whether the clinical benefit of aspiration thrombectomy relative to IV r-tPA (recombinant tissue-type plasminogen activator) may be greater at longer TL. METHODS—THERAPY was a randomized trial of aspiration thrombectomy plus IV r-tPA versus IV r-tPA alone in large-vessel stroke patients with prospective TL measurement ≥8 mm. In this post hoc study, we evaluated the association of TL with trial end points and potential endovascular treatment effect, using univariate, multivariable, and multiplicative interaction analyses. RESULTS—TL data were available for all 108 patients (28% internal carotid artery, 62% M1, and 10% M2). Median TL was 14.0 mm (interquartile range, 9.7–19.5 mm). Longer TL was associated with worse outcome (90-day modified Rankin Scale scoreodds ratio, 1.24 per 5-mm TL increment; 95% confidence interval, 1.04–1.52; P=0.02), even after adjusting for key outcome predictors (adjusted P=0.004). Longer TL was also associated with more serious adverse events (adjusted P=0.01), more symptomatic hemorrhages (adjusted P=0.03), and increased mortality (adjusted P=0.01). No significant relationship was observed between TL and angiographic reperfusion (modified thrombolysis in cerebral ischemia 2b-3), but greater TL was associated with longer endovascular procedural times (ρ=0.36; P=0.045). Increasing TL was associated with greater aspiration thrombectomy treatment effect (interaction term P=0.03). This might be related to a potentially stronger adverse effect of increasing TL on 90-day modified Rankin Scale for patients treated with IV r-tPA (ρ=0.39; P=0.01) compared with intra-arterial therapy (ρ=0.20; P=0.165). CONCLUSIONS—Ischemic stroke patients with longer symptomatic thrombi have worse 90-day clinical outcomes but may have a greater relative benefit of aspiration thrombectomy over IV r-tPA alone. CLINICAL TRIAL REGISTRATION—URLhttp://www.clinicaltrials.gov. Unique identifierNCT01429350.