Endovascular thrombectomy with or without systemic thrombolysis?
OBJECTIVE
Current recommendations advocate that pretreatment with intravenous thrombolysis (IVT) should first be offered to all eligible patients with emergent large vessel occlusion (ELVO) before an endovascular thrombectomy (ET) procedure. However, there are observational data that question the safety and efficacy of IVT pretreatment in patients with ELVO.


METHODS
We performed a meta-analysis of the included subgroups from ET randomized controlled trials (RCTs) to evaluate the comparative efficacy between direct ET without IVT pretreatment and bridging therapy (IVT and ET) in patients with ELVO.


RESULTS
We included a total of seven RCTs, including 1764 patients with ELVO (52.8% men). Patients receiving bridging therapy (IVT followed by ET) had lower rates (p= 0.041) of 90-day death/severe dependency (modified Rankin Scale-score of 5-6; 19.0%, 95% CI: 14.1-25.1%) compared with patients receiving only ET (31.0%, 95% CI: 21.2-42.9%). Moreover, patients receiving IVT and ET had a nonsignificant (p= 0.389) trend towards higher 90-day functional independence rates (51.4%, 95% CI: 42.5-60.1%) compared with patients undergoing only ET (41.7%, 95% CI: 24.1-61.7%). Finally, shift-analysis uncovered a nonsignificant trend towards functional improvement at 90 days for bridging therapy over ET (cOR = 1.28, 95% CI: 0.91-1.89;p= 0.155). It should be noted that patients included in the present meta-analysis were not randomized to receive IVT, and thus the two groups (bridging therapyversusET monotherapy) may differ in terms of baseline characteristics and, in particular, in terms of onset to groin puncture time and thus the risk of confounding bias cannot be ruled out.


CONCLUSIONS
Despite the limitations and the risk of confounding bias, our findings contradict the recent notion regarding potential equality between ET and bridging therapy in ELVO patients and suggest that IVT and ET are complementary therapies that should be pursued in a parallel and noncompeting fashion.
Second Department of Neurology, Attikon University General Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, Athens, 15344, Greece.
Georgios
G
Tsivgoulis
Second Department of Neurology, Attikon University General Hospital, School of Medicine, University of Athens, Athens, Greece Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece.
Aristeidis H
AH
Katsanos
Department of Primary Education, University of Ioannina, Ioannina, Greece Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece.
Dimitris
D
Mavridis
Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA Australian Catholic University, Sydney, Australia.
Anne W
AW
Alexandrov
Acute Stroke Unit and Department of Interventional Neuroradiology, Metropolitan Hospital, Piraeus, Greece.
Georgios
G
Magoufis
Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee Health Science Center, Memphis, TN, USA.
Adam
A
Arthur
Stroke Unit, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy.
Valeria
V
Caso
Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Minden, Germany.
Peter D
PD
Schellinger
Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
Andrei V
AV
Alexandrov
acute ischemic stroke; emergent large vessel occlusion; intravenous thrombolysis; mechanical thrombectomy; meta-analysis