IV Thrombolysis Before Thrombectomy in Carotid Artery Dissection-Related Large-Vessel Occlusion

BACKGROUND AND OBJECTIVES: The benefit of IV thrombolysis (IVT) before thrombectomy in patients with anterior-circulation large-vessel occlusion (LVO) due to carotid artery dissection (CAD) remains uncertain. We aimed to evaluate the safety and efficacy of IVT in this specific population in clinical practice.

METHODS: This study included patients from the Carotid Dissection Thrombectomy vs Medical Treatment collaboration and the Endovascular Treatment in Ischemic Stroke registry with anterior-circulation LVO due to CAD who were treated with thrombectomy, with or without prior IVT. The coprimary outcomes were favorable functional outcome at 3 months (modified Rankin Scale 0-2) and successful reperfusion (thrombolysis in cerebral infarction score ≥2b). The safety end point was symptomatic intracranial hemorrhage (sICH). Inverse probability of treatment weighting was applied to adjust for baseline imbalances, and weighted Poisson regression models were used to estimate adjusted risk ratios (aRRs).

RESULTS: A total of 1,091 patients (mean age 53.0 years, 74.0% men) were included, of whom 571 patients received IVT prior thrombectomy and 520 underwent thrombectomy only. IVT before thrombectomy was associated with a higher likelihood of favorable functional outcome (aRR 1.16, 95% CI 1.03-1.30, p = 0.013) and successful reperfusion (aRR 1.34, 95% CI 1.18-1.53, p < 0.001). No association was observed with sICH (aRR 0.69, 95% CI 0.41-1.16, p = 0.161). Subgroup analyses showed that the functional benefit of IVT was pronounced in patients with higher admission NIH Stroke Scale scores ( p interaction = 0.039).

DISCUSSION: IVT prior thrombectomy was associated with improved functional outcome and higher reperfusion success in patients with anterior-circulation LVO due to CAD, without an increase in sICH. The association with functional outcome was largely driven by patients presenting with higher admission stroke severity.

CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that IVT before thrombectomy was associated with improved functional outcome and higher reperfusion success in patients with anterior-circulation LVO due to CAD, without an increase in sICH.