Background & Purpose: Current AHA recommendations advocate that pretreatment with intravenous thrombolysis (IVT) should first be offered to all eligible acute ischemic stroke (AIS) patients with emergent large vessel occlusion (ELVO) before an endovascular thrombectomy (ET) procedure. Nevertheless, recent single-center observational studies question the utility of IVT pretreatment in ELVO patients eligible for systemic thrombolysis and advocate ET monotherapy. We sought to evaluate the comparative efficacy between ET and bridging therapy (IVT&ET) in AIS due to ELVO.
Methods: We performed mixed-effects subgroup analyses, according to IVT pretreatment status of both functional independence [modified Rankin Scale (mRS) of 0-2)] and death/dependency (mRS of 5-6) at 90 days using available RCTs that evaluated the safety and efficacy of ET with stent-retrievers in comparison to standard therapy. We additionally performed an ordinal logistic regression analysis of individual patient data on the distribution of 3-month mRS scores (shift analysis) between the two groups.
Results: We identified 7 eligible RCTs including 1764 ELVO patients (53% men), and 108 patients randomized to ET without IVT pretreatment. Patients receiving bridging therapy (BT) had lower rates (p=0.041) of 90-day death/dependency (19%, 95%CI: 14%-25%) compared to patients receiving only ET (31%, 95%CI: 21%-43%; Figure). Similarly, shift-analysis favored a trend for BT over ET in terms of better 90-day functional outcome (common OR=0.78, 95%CI: 0.53-1.10; p=0.155).
Conclusion: Our findings indicate that pretreatment with IVT prior ET in ELVO patients may be associated with lower rates of three-month death/dependency and a trend towards more favorable functional outcomes. Until the results from head-to-head RCTs comparing BT to ET monotherapy become available, our findings support AHA guidelines recommending delivery of tPA to appropriate ELVO candidates undergoing ET.