Bridging Thrombolysis before Endovascular Therapy Improves Functional Outcomes in Medium-Large Core Stroke within 4.5...

The benefit of intravenous thrombolysis (IVT) before endovascular therapy (EVT) in patients with acute ischemic stroke (AIS) with medium-large infarct core (MLIC) remains uncertain.

We conducted a retrospective analysis of a prospective multicenter registry in Vietnam (August 2023-September 2024). We included patients with AIS large-vessel occlusion in the anterior circulation within 4.5 h of onset, an Alberta Stroke Program Early CT Score (ASPECTS) < 6, and a National Institutes of Health Stroke Scale (NIHSS) ≥ 6 at admission. The primary outcome was functional ambulation (defined as mRS 0-3) at 90 days of follow-up. Secondary outcomes were functional independence (mRS 0-2), mRS shift analysis, and rates of successful reperfusion (modified thrombolysis in cerebral infarction 2b-3). Safety outcomes were defined by symptomatic intracranial hemorrhage (sICH) according to SITS-MOST criteria and 90-day mortality. Outcomes between the bridging therapy and EVT-alone groups were compared using propensity score-matched (PSM) analysis.

Of 403 MLIC patients undergoing EVT, 148 presented within 4.5 h, 59 (39.9%) received bridging IVT. After PSM, we analyzed 72 patients, with 36 in each group. The median age, proportion of males, baseline ASPECTS, and NIHSS scores were similar between the two groups. The bridging group achieved higher rates of functional ambulation (75% vs. 41.7%, OR 4.2, 95% CI 1.54-11.46). Regarding safety, there was no statistically significant difference in symptomatic intracerebral hemorrhage (8.3% vs. 11.1%, p = 1.0) or mortality (8.3% vs. 19.4%, p = 0.17), though the confidence intervals were wide.

Our study suggests that bridging therapy in patients with acute medium-large ischemic core within 4.5 h of onset results in better functional outcomes than EVT alone without increasing the sICH rate. Further studies are required to assess the safety and efficacy of bridging therapy.