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IV Thrombolysis in Endovascular Treatment for Anterior Circulation LVO Stroke
Quick Takes
- It is controversial whether treatment with IV thrombolysis in addition to endovascular treatment—as opposed to endovascular treatment alone—provides additional benefit to acute stroke patients presenting with anterior circulation large vessel occlusion (LVO).
- In this meta-analysis using patient-level data from six randomized controlled trials, endovascular therapy alone was not shown to be noninferior to combination therapy with IV thrombolysis and endovascular therapy for these patients.
- Current AHA/ASA Guidelines provide a Class 1 Level A recommendation stating, “Patients eligible for IV alteplase should receive IV alteplase even if mechanical thrombectomy is being considered.” The results of this study lend support to that recommendation.
Study Questions:
Is treatment with endovascular therapy alone noninferior to combination treatment with intravenous (IV) tissue plasminogen activator (tPA) and endovascular therapy in patients presenting with anterior circulation large vessel occlusion (LVO) strokes?
Methods:
This is a meta-analysis using patient-level data from six randomized controlled trials evaluating treatment with endovascular therapy alone versus treatment with both IV tPA and endovascular therapy. The primary outcome was modified Rankin scale (mRS) score at 90 days, where lower scores signify less disability.
Results:
Of 2,314 total subjects enrolled across 15 countries, 1,153 were assigned to receive endovascular therapy alone and 1,160 were assigned to receive both IV tPA (98% received alteplase) and endovascular therapy. The median 90-day mRS score for patients who received endovascular therapy alone was 3 (IQR 1-5), whereas the median mRS score for patients who received combination treatment was more favorable at 2 (IQR 1-4). While lower odds of intracranial hemorrhage was observed in the endovascular-only group (adjusted odds ratio [aOR], 0.82; 95% confidence interval [CI], 0.68-0.99), no difference was observed in the rate of symptomatic intracerebral hemorrhage (aOR, 0.73; 95% CI, 0.46-1.14) or 90-day mortality (aOR, 1.07; 95% CI, 0.83-1.39) between the two groups.
Conclusions:
In this meta-analysis using patient-level data across six randomized controlled trials, endovascular therapy alone was not shown to be noninferior to combination therapy with IV tPA and endovascular therapy for acute stroke patients presenting with anterior circulation LVO.
Perspective:
This topic is of interest because—at endovascular-capable centers—it would be considerably easier and quicker to forego IV thrombolysis in favor of a direct-to-endovascular approach for stroke patients with LVO who are eligible for mechanical thrombectomy. However, the results of this study do not support that approach. Current American Heart Association/American Stroke Association (AHA/ASA) Guidelines provide a Class 1 Level A recommendation stating, “Patients eligible for IV alteplase should receive IV alteplase even if mechanical thrombectomy is being considered.” The results of this study lend support to that recommendation.
Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Lipid Metabolism
Keywords: Endovascular Procedures, Stroke, Thrombectomy, Tissue Plasminogen Activator
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