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Updated: Nov 3, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without IV Thrombolysis
Niaz Ahmed1, Michael Mazya2, Ana Paiva Nunes2
1From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden. niaz.ahmed@ki.se.
Objective:
To test the hypothesis that IV thrombolysis (IVT) treatment before endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the Safe Implementation of Treatment in Stroke-International Stroke Thrombectomy Register (SITS-ISTR).
Methods:
We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014 to 2019. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery, and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-Monitoring Study. We performed propensity score-matched (PSM) and multivariable logistic regression analyses.
Results:
Of 6,350 patients from 42 centers, 3,944 (62.1%) received IVT. IVT + EVT-treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure, and prestroke disability. PSM analysis showed that IVT + EVT-treated patients had a higher rate of functional independence than patients treated with EVT alone (46.4% vs 40.3%, p < 0.001) and a lower rate of death at 3 months (20.3% vs 23.3%, p = 0.035). SICH rates (3.5% vs 3.0%, p = 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM.
Conclusion:
Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS-ISTR. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding, and possible residual confounding by indication.
Classification Of Evidence:
This study provides Class II evidence that IVT before EVT increases the probability of functional independence at 3 months compared to EVT alone.
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