Abstract

Background and purpose: Mechanical thrombectomy (MT) is an effective treatment for patients with internal carotid artery (ICA) occlusion acute ischaemic stroke. It remains unclear whether intravenous thrombolysis (IVT) before MT confers any benefit or may result in harm. This study compared the outcomes of acute ICA stroke patients who were treated with direct MT versus combined IVT plus MT.

Methods: This multicenter retrospective cohort study included patients treated for acute ICA stroke from five comprehensive stroke centers between January 2015 and December 2019. Patients received direct MT or combined bridging IVT plus MT. The primary outcome was a favorable functional outcome defined as a modified Rankin Scale (mRS) 0–3 measured at discharge. Secondary outcome measures included mRS at 90 days, mortality, and complications such as symptomatic intracranial hemorrhage (sICH), subarachnoid hemorrhage (SAH), and embolism of thrombus to new territories.

Results: Among 352 patients, 178 (50.6%) underwent bridging IVT followed by MT, and 174 (49.4%) underwent direct MT. The mean, standard deviation age was 69.8±14.6 years, 50.9% were male, and the median National Institutes of Health Stroke Scale was 16 (interquartile range). Patients who underwent bridging IVT had better functional outcomes (mRS 0-3) on discharge than those who underwent direct MT (24.6% vs 38.0%, P=0.025). On multivariable analyses, bridging IVT was not associated with improvement in 90-day mRS score, decreased mortality, or difference in rate of complications compared to direct MT. In subgroup analyses, patients with underlying large artery atherosclerosis treated with bridging IVT compared to direct MT had a higher rate of favorable functional outcome at 90 days (33.9% vs. 14.0%, P=0.022)

Conclusions: Bridging IVT is associated with better functional outcomes than direct MT in ICA stroke. In the subgroup of patients with large-artery atherosclerosis, bridging IVT may also confer benefit.