Trends in Utilization and Outcomes of Thrombectomy Alone versus Adjunctive Thrombolysis in Acute Ischemic Stroke

Purpose: In years 2020 and 2021, three clinical trials were published—the DEVT, DIRECT-MT, and SKIP trials—all investigating the efficacy of various endovascular treatment for patients with acute ischemic stroke (AIS). Two of the three trials (DEVT and DIRECT-MT) demonstrated noninferiority of mechanical thrombectomy (MT) alone compared with MT plus intravenous tissue plasminogen activator (IV-tPA). Herein, we compare the trends in use and outcomes of patients with AIS undergoing MT plus IV-tPA and MT alone using a national inpatient database.

Materials and Methods: The Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) was queried between 2006 and 2018 for patients undergoing MT for AIS. Patients who received MT alone were compared with those who underwent MT plus IV-tPA regarding 90-day poor functional outcome (akin to modified Rankin scale >3), inpatient mortality rate, and patient profile for tPA usage. Cochran-Armitage test was conducted to assess the linear trend of utilization of tPA. All estimates were nationalized using discharge weights provided by HCUP.

Results: A total of 109,385 admissions were identified pertaining to MT for AIS from 2006 to 2018. Of these, 68,940 (62.0%) admission involved MT alone. There was an increase in the trend of utilization of MT without IV-tPA among patients with AIS (trend: 3.27%; P < 0.001) per year, with 52.0% in 2006 to 72.0% in 2018. Multivariable regression analysis regarding patient profile indicated that patients who identified as Black (odds ratio [OR], 0.83; P < 0.001) or Hispanic (OR, 0.83; P = 0.002) were more likely to undergo MT alone compared with those who identified as white. Additionally, those in the top quartile of household income had lower odds of undergoing MT alone compared with those in the lowest quartile (OR, 0.90; P = 0.040). Admissions in urban teaching hospitals had higher odds of receiving MT alone compared with those in urban nonteaching hospitals (OR, 1.61; P < 0.001). Regarding mortality rate, those who received MT alone had similar odds of death compared with those receiving MT plus IV-tPA (OR, 1.01; P = 0.80). Last, the MT-alone group had higher odds of poor functional outcome compared with the MT plus IV-tPA group (OR, 1.14; P = 0.002).

Conclusions: Our results indicate that MT alone was used more frequently than MT plus IV-tPA among patients with AIS. Both treatment groups had similar odds of mortality, but the MT alone group had higher odds of 90-day poor functional outcome compared with the MT plus IV-tPA group. These results support the findings in the three recent clinical trials.