Value of Thrombolysis before Thrombectomy for Acute Ischemic Stroke

Both intravenous thrombolysis with alteplase and endovascular thrombectomy (EVT) have demonstrated value for select patients with acute ischemic stroke. When patients arrive within 4.5 hours after stroke onset, alteplase is frequently administered prior to EVT. However, some have questioned whether similar results can be achieved even without alteplase administration. These authors conducted a randomized trial in three European countries. Patients who presented to EVT-capable hospitals within 4.5 hours after stroke onset were randomly assigned to either alteplase plus EVT or EVT alone. The primary endpoint was 90-day disability status, as measured by the modified Rankin Scale (mRS). Secondary endpoints included mortality and symptomatic intracerebral hemorrhage.

Among the 539 patients (median age, 71 years; 57% men), strokes were fairly severe (median NIH stroke scale score, 16). Most vascular occlusions involved the terminal internal carotid artery or proximal middle cerebral artery. For patients who received alteplase, the door-to-needle time was impressive at 31 minutes. The median mRS score was 3 in the EVT-alone group compared to 2 (slightly less disability) in the EVT-plus-alteplase group. Statistically, EVT alone was neither superior nor noninferior to EVT plus alteplase. Mortality at 90 days was slightly higher in the EVT-alone group (20.5% vs. 15.8%), but the adjusted odds ratio was not significant. Symptomatic hemorrhage rates were not significantly different (5.9% vs. 5.3%).