Mechanical Thrombectomy with or Without Intravenous Thrombolysis?

Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York Presbyterian/Weill Cornell Medical College

SOURCE: Trifan G, Biller J, Testai FD. Mechanical thrombectomy vs bridging therapy for anterior circulation large vessel occlusion stroke: Systematic review and meta-analysis. Neurology 2022;98:e1361-e1373.

Current stroke treatment guidelines recommend combined use of intravenous thrombolysis with alteplase prior to endovascular thrombectomy for patients with large vessel occlusion. This often is referred to as “bridging therapy.” However, there continues to be controversy surrounding this recommendation, and these investigators undertook a systematic review and meta-analysis of completed therapeutic trials to help resolve the controversy.

All reported databases that were available, up to and including Oct. 29, 2021, were reviewed and analyzed, comparing rates of functional independence and mortality at 90 days, symptomatic intracranial hemorrhage, and successful recanalization rates for patients who were treated with mechanical thrombectomy alone, or with bridging therapy. Comparisons were calculated using odds ratio with a random effects meta-analysis. A total of 41 studies, which included 14,885 patients, were identified and analyzed. The bridging therapy group had a 29% higher odds ratio for functional independence, as well as higher probability of successful reperfusion, and a 31% decrease in odds ratio for mortality, compared to patients treated with mechanical thrombectomy alone. The rate of symptomatic intracranial hemorrhage was similar between the two groups. Six of the studies that the investigators reviewed were randomized controlled trials with analysis done in patients who presented directly to thrombectomy-capable centers. When an analysis was done of these studies only, there were no differences observed in functional independence or mortality.

Overall, the odds for successful reperfusion, improved functional independence, and lower mortality for the entire data set favored the use of bridging therapy over mechanical thrombectomy alone. Patients brought directly to thrombectomy-capable centers had outcomes that were the same for bridging therapy vs. thrombectomy alone, and further study and analysis will need to be done.

Direct transport to a thrombectomy-capable center most likely results in more rapid endovascular treatment, but this needs to be determined in a more systematic way. There also is growing experience with alternative thrombolytic agents, such as tenecteplase, which can be administered more quickly and may have advantages over alteplase. Further study is warranted.