Comparison of multimodal intra-arterial treatment versus intravenous thrombolysis for hypertensive patients with severe large vessel cerebral infarction

Abstract

Since intravenous thrombolysis (IVT) is often associated with poor outcomes in hypertensive patients with severe acute cerebral infarction (ACI) due to occlusions of the internal carotid, basilar, or proximal middle cerebral artery, we evaluated whether multimodal intra-arterial treatment (IAT) might improve functional outcomes in this patient population. We retrospectively reviewed the charts of eligible patients who underwent multimodal IAT including intra-arterial thrombolysis, mechanical thrombectomy, balloon and/or stent angioplasty (IAT group) or IVT alone (IVT group). Outcomes included the revascularization rate 24 hours postprocedure, the frequency of survival at 7, 90, and 180 days postonset, and a measure of functional outcomes using the modified Rankin Scale (mRS). The IAT group included 62 patients and the IVT group included 31 patients. Multimodal IAT increased the revascularization rate at 24 hours (p<0.001) and the frequency of survival and functional independence (mRS ≤2) at 7 days (p<0.001 and p=0.018, respectively), 90 days (both p<0.001), and 180 days (both p<0.001). Independent predictors of longer survival were treatment with multimodal IAT (HR 0.1; 95% CI 0.0 to 0.4; p<0.001) and revascularization (HR 0.1; 95% CI 0.0 to 0.4; p<0.001), whereas a longer duration from onset to treatment was a risk factor for death (HR 1.4; 95% CI 1.2 to 1.8; p<0.001). There was no significant between-group difference for symptomatic hemorrhagic transformation. This study found that for patients with severe hypertensive ACI with large vessel occlusions, multimodal IAT improved the outcomes, including early revascularization, survival, and functional outcome.

Keywords: acute cerebral infarction; hypertension; intra-arterial treatment; intravenous thrombolysis; large vessel occlusion; revascularization.