Intravenous Thrombolysis Before Endovascular Treatment in Posterior Circulation Occlusions: A MR CLEAN Registry Study
Authors: Knapen Robrecht R.M.M. , Pirson F. Anne V. , Langezaal Lucianne C.M. , Brouwer Josje , Majoie Charles B.L.M. , Emmer Bart J. , Vos Jan-Albert , van Doormaal Pieter-Jan , Yoo Albert J. , Bruggeman Agnetha A.E. , Lycklama à Nijeholt Geert J. , van der Leij Chirstiaan , van Oostenbrugge Robert J. , van Zwam Wim H. , Schonewille Wouter J. , Dippel Diederik W.J. , van der Lugt Aad , Roos Yvo B.W.E.M. , Boiten Jelis , Jansen Ivo G.H. , Mulder Maxim J.H.L. , Goldhoorn Robert-Jan B. , Compagne Kars C.J. , Kappelhof Manon , den Hartog Sanne J. , Hinsenveld Wouter H. , Dippel Diederik W.J. , Roozenbeek Bob , van der Lugt Aad , Roos Yvo B.W.E.M. , Wermer Marieke J.H. , van Walderveen Marianne A.A. , van Es Adriaan C.G.M. , Staals Julie , Hofmeijer Jeannette , Martens Jasper M. , Boiten Jelis , de Bruijn Sebastiaan F. , van Dijk Lukas C. , Bart van der Worp H. , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Vries J. , de Kort Paul L.M. , van Tuijl Julia , Peluso Jo P. , Fransen Puck , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Uyttenboogaart Maarten , Eschgi Omid , Bokkers Reinoud P.H. , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Yo Lonneke S.F. , den Hertog Heleen M. , Sturm Emiel J.C. , Brouwers Paul J.A.M. , van Walderveen Marianne A.A. , Sprengers Marieke E.S. , Jenniskens Sjoerd F.M. , van den Berg René , Beenen Ludo F.M. , Postma Alida A. , Roosendaal Stefan D. , van der Kallen Bas F.W. , van den Wijngaard Ido R. , van Es Adriaan C.G.M. , Martens Jasper M. , Yo Lonneke S.F. , Bot Joost , Meijer Anton , Ghariq Elyas , Bokkers Reinoud P.H. , van Proosdij Marc P. , Menno Krietemeijer G. , Peluso Jo P. , Boogaarts Hieronymus D. , Lo Rob , Dinkelaar Wouter , Appelman Auke P.A. , Hammer Bas , Pegge Sjoert , van der Hoorn Anouk , Vinke Saman , Cornelissen Sandra , Brans Rutger , Dippel Diederik W.J. , van der Lugt Aad , Roos Yvo B.W.E.M. , Boiten Jelis , Hofmeijer Jeannette , Martens Jasper M. , Bart van der Worp H. , Lo Rob H. , Hofmeijer Jeannette , Zwenneke Flach H. , Lingsma Hester F. , el Ghannouti Naziha , Sterrenberg Martin , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , Simons Michelle , Vossers Marjolein , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , Messchendorp Gert , Nicolaij Nynke , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert Maureen , Verheesen Sabrina , Jeurrissen D. , Bos Erna , Drabbe Yvonne , Sandiman Michelle , Aaldering Nicoline , Zweedijk Berber , Vervoort Jocova , Ponjee Eva , Romviel Sharon , Kanselaar Karin , Barning Denn , Venema Esmee , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R.M. , Muijres Daan , de Jong Anouk , Berkhemer Olvert A. , Boers Anna M.M. , Huguet J. , Groot P.F.C. , Mens Marieke A. , van Kranendonk Katinka R. , Treurniet Kilian M. , Tolhuisen Manon L. , Alves Heitor , Weterings Annick J. , Kirkels Eleonora L.F. , Voogd Eva J.H.F. , Schupp Lieve M. , Collette Sabine L. , Groot Adrien E.D. , LeCouffe Natalie E. , Konduri Praneeta R. , Prasetya Haryadi , Arrarte-Terreros Nerea , Ramos Lucas A. , Boodt Nikki 
Published: January 2024

BACKGROUND:
The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry.

METHODS:
Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0–3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied.

RESULTS:
A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61–1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33–8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT.

CONCLUSIONS:
We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation.