Bridging thrombolysis improves survival rates at 90 days compared with direct mechanical thrombectomy alone in acute ischemic stroke due to basilar artery occlusion: a systematic review and meta-analysis of 1096 patients

Abstract

BackgroundMechanical thrombectomy (MT) is an effective treatment for patients with acute ischemic stroke (AIS) from basilar artery occlusion (BAO).ObjectiveTo compare the clinical outcomes of MT, with and without bridging intravenous thrombolysis (IVT), in acute BAO through a systematic review and meta-analysis of the current literature.MethodsSystematic searches of Medline, EMBASE, and Cochrane Central were undertaken on August 1, 2022. Good functional outcome defined as 90-day modified Rankin Scale score 0–2 was the primary outcome measure. Secondary outcome measures were 90-day mortality, successful post-thrombectomy recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracranial hemorrhage (sICH), and subarachnoid hemorrhage (SAH).ResultsThree studies reporting 1096 patients with BAO AIS were included in the meta-analysis. No significant differences in good functional outcome were detected between the two groups (RR=1.28 (95% CI 0.86 to 1.92); p=0.117). However, specifically patients with large artery atherosclerosis (LAA) benefited from bridging IVT (OR=2.52 (95% CI 1.51 to 4.22); p<0.001) with better functional outcomes. There was a significantly lower 90-day mortality rate for patients who underwent bridging IVT compared with MT alone (RR=0.70 (95% CI 0.62 to 0.80); p=0.008). No significant differences were detected in rates of post-treatment recanalization (RR=1.01 (95% CI 0.35 to 2.91); p=0.954), sICH (RR=0.96 (95% CI 0.66 to 1.42); p=0.724), and SAH (RR=0.93 (95% CI 0.31 to 2.83); p=0.563).ConclusionsIn patients with AIS due to BAO, bridging IVT was associated with lower mortality rates at 90 days, compared with direct MT. There were no improved functional outcomes or increased sICH or SAH between both arms, However, patients with LAA benefited from bridging IVT, with better functional outcomes.

Endovascular thrombectomy with and without preceding thrombolysis in posterior circulation stroke – insights from STAR

“…In addition, the change in NIHSS could be explained by the significantly shorter interval between stroke symptom onset and puncture time in the IVT group and thus is most likely a selection bias. Previous studies reported a significantly longer interval between stroke symptom onset and puncture time in patients treated with EVT alone compared to IVT followed by thrombectomy as well (Siow et 13,19 Multiple regression models cannot fully account for the longer time interval between stroke onset and puncture in the EVT alone group, which might have influenced the outcomes and is a limitation of this study. Interestingly, Nie et al 18 reported an improved functional outcome in the IVT group despite the highest median onset ).…”

“…Previous studies reported a significantly longer interval between stroke symptom onset and puncture time in patients treated with EVT alone compared to IVT followed by thrombectomy as well (Siow et al: 330 min vs. 240 min [mean] and Kohli et al: 711 min vs. 313 min [median]). 13,19 Multiple regression models cannot fully account for the longer time interval between stroke onset and puncture in the EVT alone group, which might have influenced the outcomes and is a limitation of this study. Interestingly, Nie et al 18 reported an improved functional outcome in the IVT group despite the highest median onset to puncture time of 510 min in the IVT group (IQR 378-763).…”

“…Conversely, a meta-analysis of 1096 patients demonstrated that IVT followed by thrombectomy was associated with lower mortality rates at 90 days compared with EVT alone in patients with acute BA occlusion, while no differences have been observed concerning functional outcomes or rates of intracranial hemorrhages. 13 The aim of this study is to investigate the effect of IVT prior to EVT in patients with PC-LVO compared to EVT alone using a large, international `real world` stroke database. Given the retrospective nature of this study, the results are purely observational and to be interpreted as hypotheses-generating to encourage further prospective studies.…”

“…Conversely, a meta-analysis of 1096 patients demonstrated that IVT followed by thrombectomy was associated with lower mortality rates at 90 days compared with EVT alone in patients with acute BA occlusion, while no differences have been observed concerning functional outcomes or rates of intracranial hemorrhages. 13…”

What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke?

“…45 With regard to bridging IVT, a recent meta-analysis concluded that patients with BAO had lower mortality and, in the case of large vessel atherosclerosis, also better functional outcome when they received IVT prior to EVT compared with direct EVT. 57 A pooled analysis of the EXTEND-IA TNK trial and the BATMAN registry compared tenecteplase and alteplase before EVT for BAO, revealing a higher pre-EVT recanalization rate with tenecteplase (26 vs. 7%) without an increase in the frequency of sICH. 58…”