Outcomes of Bridging Intravenous Thrombolysis Versus Endovascular Therapy Alone in Late-Window Acute Ischemic Stroke
Authors: Demeestere Jelle , Qureshi Muhammad M. , Vandewalle Lieselotte , Wouters Anke , Strbian Daniel , Nogueira Raul G. , Nagel Simon , Yamagami Hiroshi , Puetz Volker , Abdalkader Mohamad , Haussen Diogo C. , Mohammaden Mahmoud H. , Möhlenbruch Markus A. , Olivé-Gadea Marta , Winzer Simon , Ribo Marc , Michel Patrik , Marto João Pedro , Tanaka Kanta , Yoshimura Shinichi , Martinez-Majander Nicolas , Caparros Francois , Henon Hilde , Tomppo Liisa , Dusart Anne , Bellante Flavio , Ramos João Nuno , Jesser Jessica , Sheth Sunil A. , Ortega-Gutiérrez Santiago , Siegler James E. , Nannoni Stefania , Kaesmacher Johannes , Dobrocky Tomas , Salazar-Marioni Sergio , Farooqui Mudassir , Virtanen Pekka , Ventura Rita , Zaidi Syed F. , Castonguay Alicia C. , Uchida Kazutaka , Puri Ajit S. , Sakai Nobuyuki , Toyoda Kazunori , Farzin Behzad , Masoud Hesham E. , Klein Piers , Bui Jenny , Rizzo Federica , Kaiser Daniel P.O. , Desfontaines Philippe , Strambo Davide , Cordonnier Charlotte , Lin Eugene , Ringleb Peter A. , Roy Daniel , Zaidat Osama O. , Fischer Urs , Raymond Jean , Lemmens Robin , Nguyen Thanh N. 
Published: May 2024

BACKGROUND:
Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well.

METHODS:
We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT.

RESULTS:

Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively,
P
value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well—start of EVT median 560 minutes [interquartile range, 432–791] versus 724 minutes [interquartile range, 544–912];
P
<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89–1.19];
P
=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81–1.75];
P
=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38–1.48];
P
=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89–1.46];
P
=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well.

CONCLUSIONS:
In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT.

REGISTRATION:

URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT04096248.