DIRECT MT

Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke

Yang. N Engl J Med 2020; 382:1981-1993. DOI: 10.1056/NEJMoa2001123

Clinical Question

-  In patients with acute anterior ischaemic stroke, is endovascular thrombectomy alone, compared with endovascular thrombectomy preceded by intravenous alteplase, noninferior with respect to modified Rankin score at 90 days?

N = 636, 41 centres over 18 provinces in China

Authors’ Conclusions
-  In patients with acute ischaemic stroke with large-vessel occlusion, endovascular thrombectomy alone was noninferior to thrombectomy preceded by alteplase administered within 4.5 hours after symptom onset, within a relative margin in the confidence interval of 20% in the shift between categories of the modified Rankin scale at 90 days

The Bottom Line
-  This is an interesting study which likely applies mainly to stroke centres with thrombectomy capability, but unclear whether the data are robust enough to affect practice, particularly at smaller facilities without thrombectomy capability