Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial - Inserm - Institut national de la santé et de la recherche médicale Access content directly
Journal Articles Journal of Neurointerventional Surgery Year : 2023

Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial

1 University of Bern
2 Inselspital - Bern University Hospital [Berne]
3 Helsingin yliopisto = Helsingfors universitet = University of Helsinki
4 HUS - Helsinki University Hospital [Finland]
5 Département de Neuroradiologie [Centre Hospitalier Lyon Sud - HCL]
6 Service Neuroradiologie Diagnostique et Thérapeutique [CHU Toulouse]
7 University of Toronto
8 Toronto Western Hospital
9 Département Neurologie [CHU Toulouse]
10 CHU Nantes - Centre hospitalier universitaire de Nantes
11 Service de Radiologie [CHU Rouen]
12 Service de neurologie [Rouen]
13 IADI - Imagerie Adaptative Diagnostique et Interventionnelle
14 Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy]
15 DCAC - Défaillance Cardiovasculaire Aiguë et Chronique
16 Service de neurologie [CHRU Nancy]
17 Klinikum Nürnberg Nord
18 UMG - University Medical Center Göttingen
19 PhIND - Physiopathologie et imagerie des troubles neurologiques
20 Service de Neurologie [CHU Caen]
21 Départment de Neuroradiologie [CHU Caen]
22 CarMeN - Cardiovasculaire, métabolisme, diabétologie et nutrition
23 HCL - Hospices Civils de Lyon
24 St George’s University Hospitals
25 DNR - Bordeaux - Département de Neuro-Radiologie [Bordeaux]
26 UB - Université de Bordeaux
27 CHU Bordeaux [Bordeaux]
28 UKA - Universitätsklinikum RWTH Aachen - University Hospital Aachen [Aachen, Germany]
29 Service Neuroradiologie diagnostique et interventionnelle [Hôpital Foch]
30 Vall d'Hebron University Hospital [Barcelona]
31 CHU Limoges
32 Service de neurologie [Reims]
33 CHU Reims - Centre Hospitalier Universitaire de Reims
34 UNIL - Université de Lausanne = University of Lausanne
35 CHUV - Centre Hospitalier Universitaire Vaudois [Lausanne]
36 Department of Neurology [Genève]
37 CHRU Tours - Centre Hospitalier Régional Universitaire de Tours
38 GTPUH - Germans Trias i Pujol University Hospital [Badalona, Barcelona, Spain]
39 Département de Neuroradiologie [Strasbourg]
40 Département de neurologie [Lille]
41 University hospital of Zurich [Zurich]
42 CV - CNR - cereneo Vitznau - center for Neurology & Rehabilitation [Vitznau, Switzerland]
43 Fondation Ophtalmologique Adolphe de Rothschild [Paris]
44 Service de Neuroradiologie [Brest]
45 Frankfurt University Hospital
46 SUNY Buffalo - University at Buffalo [SUNY]
47 Vanderbilt University Medical Center [Nashville]
48 Case Western Reserve University [Cleveland]
49 Alfried Krupp Krankenhaus [Essen]
50 HUG - Hôpitaux Universitaires de Genève
51 IMIBE - Institute of Medical Informatics, Biometrics and Epidemiology [ Essen, Germany]
52 University Hospital Basel [Basel]
53 Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP]
54 David Geffen School of Medicine [Los Angeles]
L. Buetikofer
  • Function : Author
G. Costentin
J. Liman
  • Function : Author
S. Saleme
  • Function : Author


BACKGROUND: We hypothesized that treatment delays might be an effect modifier regarding risks and benefits of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT). METHODS: We used the dataset of the SWIFT-DIRECT trial, which randomized 408 patients to IVT+MT or MT alone. Potential interactions between assignment to IVT+MT and expected time from onset-to-needle (OTN) as well as expected time from door-to-needle (DTN) were included in regression models. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes included mRS shift, mortality, recanalization rates, and (symptomatic) intracranial hemorrhage at 24 hours. RESULTS: We included 408 patients (IVT+MT 207, MT 201, median age 72 years (IQR 64-81), 209 (51.2%) female). The expected median OTN and DTN were 142 min and 54 min in the IVT+MT group and 129 min and 51 min in the MT alone group. Overall, there was no significant interaction between OTN and bridging IVT assignment regarding either the functional (adjusted OR (aOR) 0.76, 95% CI 0.45 to 1.30) and safety outcomes or the recanalization rates. Analysis of in-hospital delays showed no significant interaction between DTN and bridging IVT assignment regarding the dichotomized functional outcome (aOR 0.48, 95% CI 0.14 to 1.62), but the shift and mortality analyses suggested a greater benefit of IVT when in-hospital delays were short. CONCLUSIONS: We found no evidence that the effect of bridging IVT on functional independence is modified by overall or in-hospital treatment delays. Considering its low power, this subgroup analysis could have missed a clinically important effect, and exploratory analysis of secondary clinical outcomes indicated a potentially favorable effect of IVT with shorter in-hospital delays. Heterogeneity of the IVT effect size before MT should be further analyzed in individual patient meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER: URL: https://www. CLINICALTRIALS: gov ; Unique identifier: NCT03192332.
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Dates and versions

inserm-03831078 , version 1 (26-10-2022)



T. R. Meinel, J. Kaesmacher, L. Buetikofer, D. Strbian, O. F. Eker, et al.. Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial. Journal of Neurointerventional Surgery, 2023, 15 (e1), pp.e102-e110. ⟨10.1136/jnis-2022-019207⟩. ⟨inserm-03831078⟩
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