IV thrombolysis prior to mechanical thrombectomy in large vessel occlusions.
Katsanos AH, Malhotra K, Goyal N, et al.
Ann Neurol 2019; 86:395-406
The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT;IVT followed by MT), compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusions (LVO).
We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post-hoc analyses from RCTs that provided data on the outcomes of AIS patients with LVO stratified by the IVT treatment status prior to MT.
We identified 38 eligible observational studies (11,798 LVO patients, mean age 68 years, 56% treated with BT). In unadjusted analyses BT was associated with a higher likelihood of three-month functional independence (OR=1.52,95%CI:1.32-1.76), three-month functional improvement (cOR for 1-point decrease in mRS-score=1.52,95%CI:1.18-1.97), early neurological improvement (OR=1.21,95%CI:1.83-1.76), successful recanalization (OR=1.22,95%CI:1.02-1.46) and successful recanalization with less than two device passes (OR=2.28,95%CI:1.43-3.64) compared to dMT. BT was also related to a lower likelihood of three-month mortality (OR=0.64, 95%CI: 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of three-month functional independence (adjusted OR=1.55, 95%CI:1.26-1.91) and a lower odds of three-month mortality (adjusted OR=0.80,95%CI:0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR=1.24,95%CI:0.89-1.74) or symptomatic ICH (adjusted OR=0.87,95%CI:0.61-1.25).
Bridging therapy appears to be associated with improved functional independence without evidence for safety concerns, compared to direct mechanical thrombectomy, for acute ischaemic stroke patients with large vessel occlusion.