Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion
Authors: Faizy Tobias D. , Broocks Gabriel , Heit Jeremy J. , Kniep Helge , Flottmann Fabian , Meyer Lukas , Sporns Peter , Hanning Uta , Kaesmacher Johannes , Deb-Chatterji Milani , Vollmuth Philipp , Lansberg Maarten G. , Albers Gregory W. , Fischer Urs , Wintermark Max , Thomalla Götz , Fiehler Jens , Winkelmeier Laurens ,   German Stroke Registry–Endovascular Treatment Investigators, Allegiani Anna , Berrouschot Jörg , Boeckh-Behrens Tobias , Bohner Georg , Borggrefe Jan , Bormann Albrecht , Braun Michael , Dorn Franziska , Eckert Bernd , Ernemann Ulrike , Ernst Marielle , Fiehler Jens , Gerloff Christian , Gröschel Klaus , Hamann Gerhard F. , Hattingen Jörg , Henn Karl-Heinz , Keil Fee , Kellert Lars , Kraemer Christoffer , Leischner Hannes , Liman Jan , Ludolf Alexander , Nolte Christian , Nikoubashman Omid , Petersen Martina , Petzold Gabor , Poli Sven , Reich Arno , Röther Joachim , Schäfer Jan Hendrik , Schell Maximilian , Schellinger Peter , Siebert Eberhard , Stögbauer Florian , Thomalla Götz , Tiedt Steffen , Trumm Christoph , Uphaus Timo , Wunderlich Silke , Zweynert Sarah 
Published: May 2023

Importance

Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce.

Objective

To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke.

Design, Setting, and Participants

Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry–Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching.

Interventions

Mechanical thrombectomy with or without IVT.

Main Outcomes and Measures

Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death.

Results

After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P &amp;lt; .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01).

Conclusions and Relevance

These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.