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Endovascular thrombectomy with versus without intravenous thrombolysis in patients with acute basilar artery occlusion: a systematic review and meta-analysis

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Abstract

Background and purpose

The benefit and safety of intravenous thrombolysis before endovascular thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion (BAO) remains unclear. This article aims to investigate the clinical outcomes and safety of endovascular thrombectomy with versus without intravenous thrombolysis in acute BAO stroke patients.

Methods

We conducted a comprehensive search of PubMed, Embase, Cochrane, and Web of Science databases to identify relevant literature pertaining to patients with acute BAO who underwent endovascular thrombectomy alone or intravenous thrombolysis bridging with endovascular thrombectomy (bridging therapy), until January 10, 2024. The primary outcome was functional independence, defined as a score of 0–2 on the modified Rankin Scale at 90 days. The safety outcome was mortality at 90 days and symptomatic intracranial hemorrhage within 48 h. Effect sizes were computed as risk ratio (RR) with random-effect models. This study was registered in PROSPERO (CRD42023462293).

Results

A total of 528 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded. Finally, 2 RCTs and 10 cohort studies met the inclusion criteria. The findings revealed that the endovascular thrombectomy alone group had a lower rate of functional independence compared to the bridging therapy group (29% vs 38%; RR 0.78, 95% CI 0.68–0.88, p < 0.001), lower independent ambulation (39% vs 45%; RR 0.89, 95% CI 0.82–0.98, p = 0.01), and higher mortality (36% vs 28%, RR 1.22, 95% CI 1.08–1.37, p = 0.001). However, no differences were detected in symptomatic intracranial hemorrhage between the two groups (6% vs 4%; RR 1.12, 95% CI 0.74–1.71, p = 0.58).

Conclusion

Intravenous thrombolysis plus endovascular thrombectomy seemed to led to better functional independence, independent ambulation, and lower risk of mortality without increasing the incidence of intracranial hemorrhage compared to endovascular thrombectomy alone. However, given the non-randomized nature of this study, further studies are needed to confirm these findings.

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Data availability

Most of analyzed data were included in this manuscript and supplemental materials. The data generated or used during the study are available from the corresponding author by request.

References

  1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K et al (2019) Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke 50:e344–e418

    PubMed  Google Scholar 

  2. Masoud HE, Havenon Ad, Castonguay AC, Asif KS, Nguyen TN, Mehta B et al (2022) brief practice update on intravenous thrombolysis before thrombectomy in patients with large vessel occlusion acute ischemic stroke: a statement from society of vascular and interventional neurology guidelines and practice standards (gaps) committee. Stroke Vascular Intervent Neurol 2022(2):000276

    Google Scholar 

  3. Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P et al (2010) Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 41:2254–2258

    CAS  PubMed  Google Scholar 

  4. Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ et al (2018) Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med 378:1573–1582

    CAS  PubMed  Google Scholar 

  5. Yogendrakumar V, Beharry J, Churilov L, Alidin K, Ugalde M, Pesavento L et al (2023) Tenecteplase improves reperfusion across time in large vessel stroke. Ann Neurol 93:489–499

    PubMed  Google Scholar 

  6. Fischer U, Kaesmacher J, Strbian D, Eker O, Cognard C, Plattner PS et al (2022) Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial. Lancet 400:104–115

    CAS  PubMed  Google Scholar 

  7. Chandra RV, Leslie-Mazwi TM, Mehta BP, Derdeyn CP, Demchuk AM, Menon BK et al (2016) Does the use of iv tpa in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value? J Neurointerventional Surg 8:443–446

    Google Scholar 

  8. Ren Y, Churilov L, Mitchell P, Dowling R, Bush S, Yan B (2018) Clot migration is associated with intravenous thrombolysis in the setting of acute ischemic stroke. Stroke 49:3060–3062

    PubMed  Google Scholar 

  9. Leker RR, Pikis S, Gomori JM, Cohen JE (2015) Is bridging necessary? A pilot study of bridging versus primary stentriever-based endovascular reperfusion in large anterior circulation strokes. J Stroke Cerebrovascular Dis Off J Natl Stroke Associat 24:1163–1167

    Google Scholar 

  10. de Souza AC, Sebastian IA, Zaidi WAW, Nasreldein A, Bazadona D, Amaya P et al (2022) Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability, and coverage. Int J Stroke Off J Int Stroke Soc 17:990–996

    Google Scholar 

  11. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W et al (2020) Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med 382:1981–1993

    CAS  PubMed  Google Scholar 

  12. Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W et al (2021) Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke: the devt randomized clinical trial. JAMA 325:234–243

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y et al (2021) Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: The skip randomized clinical trial. JAMA 325:244–253

    PubMed  PubMed Central  Google Scholar 

  14. LeCouffe NE, Kappelhof M, Treurniet KM, Rinkel LA, Bruggeman AE, Berkhemer OA et al (2021) A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med 385:1833–1844

    CAS  PubMed  Google Scholar 

  15. Mitchell PJ, Yan B, Churilov L, Dowling RJ, Bush SJ, Bivard A et al (2022) Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial. Lancet 400:116–125

    CAS  PubMed  Google Scholar 

  16. Majoie CB, Cavalcante F, Gralla J, Yang P, Kaesmacher J, Treurniet KM et al (2023) Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials. Lancet 402:965–974

    PubMed  Google Scholar 

  17. Jovin TG, Li C, Wu L, Wu C, Chen J, Jiang C et al (2022) Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion. N Engl J Med 387:1373–1384

    PubMed  Google Scholar 

  18. Tao C, Nogueira RG, Zhu Y, Sun J, Han H, Yuan G et al (2022) Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med 387:1361–1372

    PubMed  Google Scholar 

  19. Kohli GS, Schartz D, Whyte R, Akkipeddi SM, Ellens NR, Bhalla T et al (2022) Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: a meta-analysis. J Stroke Cerebrovascular Dis Off J Natl Stroke Assoc 31:106847

    Google Scholar 

  20. Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL et al (2013) Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 44:2650–2663

    PubMed  PubMed Central  Google Scholar 

  21. Roth W, Morgello S, Goldman J, Mohr JP, Elkind MS, Marshall RS et al (2017) Histopathological differences between the anterior and posterior brain arteries as a function of aging. Stroke 48:638–644

    PubMed  PubMed Central  Google Scholar 

  22. Etchevers HC, Vincent C, Le Douarin NM, Couly GF (2001) The cephalic neural crest provides pericytes and smooth muscle cells to all blood vessels of the face and forebrain. Development 128:1059–1068

    CAS  PubMed  Google Scholar 

  23. Räty S, Nguyen TN, Nagel S, Puetz V, Alemseged F, Abdalkader M et al (2023) What is the evidence for endovascular thrombectomy in posterior circulation stroke? Semin Neurol 43:345–355

    PubMed  Google Scholar 

  24. Duvernoy HM (1999) The vascular architecture of the brain stem. In: Duvernoy HM (ed) Human brain stem vessels Including the pineal gland and information on brain stem infarction. Springer, Berlin Heidelberg, Berlin, Heidelberg, pp 143–235

    Google Scholar 

  25. Nguyen TN, Raymond J, Mahmoud M, Weill A, Roy D, Guilbert F (2008) Vertebral artery stump syndrome. J Neurol Neurosurg Psychiatry 79:91–92

    CAS  PubMed  Google Scholar 

  26. Lindsberg PJ, Pekkola J, Strbian D, Sairanen T, Mattle HP, Schroth G (2015) Time window for recanalization in basilar artery occlusion: speculative synthesis. Neurology 85:1806–1815

    PubMed  Google Scholar 

  27. Nappini S, Arba F, Pracucci G, Saia V, Caimano D, Limbucci N et al (2021) Bridging versus direct endovascular therapy in basilar artery occlusion. J Neurol Neurosurg Psychiatry 92:956–962

    PubMed  Google Scholar 

  28. Siow I, Tan BYQ, Lee KS, Ong N, Toh E, Gopinathan A et al (2022) Bridging thrombolysis versus direct mechanical thrombectomy in stroke due to basilar artery occlusion. J Stroke 24:128−+

    PubMed  PubMed Central  Google Scholar 

  29. Guo M, Yue C, Yang J, Hu J, Guo C, Peng Z et al (2023) Thrombectomy alone versus intravenous thrombolysis before thrombectomy for acute basilar artery occlusion. J Neurointerventional Surg. https://doi.org/10.1136/jnis-2023-020361

    Article  Google Scholar 

  30. Langezaal LCM, van der Hoeven E, Mont’Alverne FJA, de Carvalho JJF, Lima FO, Dippel DWJ et al (2021) Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med 384:1910–1920

    PubMed  Google Scholar 

  31. Ravindren J, Perez MA, Hellstern V, Bhogal P, Baezner H, Henkes H (2019) Predictors of outcome after endovascular thrombectomy in acute basilar artery occlusion and the 6hr time window to recanalization. Front Neurol. https://doi.org/10.3389/fneur.2019.00923

    Article  PubMed  PubMed Central  Google Scholar 

  32. Nie X, Wang D, Pu Y, Wei Y, Lu Q, Yan H et al (2022) Endovascular treatment with or without intravenous alteplase for acute ischaemic stroke due to basilar artery occlusion. Stroke Vasc Neurol 7:190–199

    PubMed  Google Scholar 

  33. Giorgianni A, Biraschi F, Piano M, Mardighian D, Gasparotti R, Frigerio M et al (2018) Endovascular treatment of acute basilar artery occlusion: Registro endovascolare lombardo occlusione basilar artery (reloba) study group experience. J Stroke Cerebrovasc Dis 27:2367–2374

    PubMed  Google Scholar 

  34. Feil K, Berndt MT, Wunderlich S, Maegerlein C, Bernkopf K, Zimmermann H et al (2023) Endovascular thrombectomy for basilar artery occlusion stroke: analysis of the german stroke registry-endovascular treatment. Eur J Neurol 30:1293–1302

    PubMed  Google Scholar 

  35. Strbian D, Sairanen T, Silvennoinen H, Salonen O, Lindsberg PJ (2014) Intravenous thrombolysis of basilar artery occlusion: thrombus length versus recanalization success. Stroke 45:1733–1738

    PubMed  Google Scholar 

  36. Strbian D, Sairanen T, Silvennoinen H, Salonen O, Kaste M, Lindsberg PJ (2013) Thrombolysis of basilar artery occlusion: impact of baseline ischemia and time. Ann Neurol 73:688–694

    PubMed  Google Scholar 

  37. Desilles JP, Loyau S, Syvannarath V, Gonzalez-Valcarcel J, Cantier M, Louedec L et al (2015) Alteplase reduces downstream microvascular thrombosis and improves the benefit of large artery recanalization in stroke. Stroke 46:3241–3248

    PubMed  Google Scholar 

  38. Fischer U, Kaesmacher J, Mendes Pereira V, Chapot R, Siddiqui AH, Froehler MT et al (2017) Direct mechanical thrombectomy versus combined intravenous and mechanical thrombectomy in large-artery anterior circulation stroke: a topical review. Stroke 48:2912–2918

    PubMed  Google Scholar 

  39. Nogueira RG, Tsivgoulis G (2020) Large vessel occlusion strokes after the direct-mt and skip trials: is the alteplase syringe half empty or half full? Stroke 51:3182–3186

    PubMed  Google Scholar 

  40. Ludovica Gramegna L, Requena M, Dinia L, Melendez F, Hernandez D, Coscojuela P et al (2019) Predictors of response to endovascular treatment of posterior circulation stroke. Eur J Radiol 116:219–224

    Google Scholar 

  41. Abdalkader M, Finitsis S, Li C, Hu W, Liu X, Ji X et al (2023) Endovascular versus medical management of acute basilar artery occlusion: a systematic review and meta-analysis of the randomized controlled trials. J Stroke 25:81–91

    PubMed  PubMed Central  Google Scholar 

  42. Cao J, Xing P, Zhu X, Chen R, Shao H, Xuan J et al (2022) Mild and moderate cardioembolic stroke patients may benefit more from direct mechanical thrombectomy than bridging therapy: a subgroup analysis of a randomized clinical trial (direct-mt). Front Neurol 13:1013819

    PubMed  PubMed Central  Google Scholar 

  43. Keselman B, Gdovinová Z, Jatuzis D, Melo TPE, Vilionskis A, Cavallo R et al (2020) Safety and outcomes of intravenous thrombolysis in posterior versus anterior circulation stroke: results from the safe implementation of treatments in stroke registry and meta-analysis. Stroke 51:876–882

    PubMed  Google Scholar 

  44. Dorňák T, Král M, Hazlinger M, Herzig R, Veverka T, Buřval S et al (2015) Posterior vs. anterior circulation infarction: demography, outcomes, and frequency of hemorrhage after thrombolysis. Int J Stroke Off J Int Stroke Soc 10:1224–1228

    Google Scholar 

  45. Lee M, Saver JL, Alger JR, Hao Q, Starkman S, Ali LK et al (2012) Blood-brain barrier permeability derangements in posterior circulation ischemic stroke: frequency and relation to hemorrhagic transformation. J Neurol Sci 313:142–146

    PubMed  Google Scholar 

  46. Alemseged F, Ng FC, Williams C, Puetz V, Boulouis G, Kleinig TJ et al (2021) Tenecteplase vs alteplase before endovascular therapy in basilar artery occlusion. Neurology 96:e1272–e1277

    CAS  PubMed  Google Scholar 

  47. Maier B, Finitsis S, Mazighi M, Lapergue B, Marnat G, Sibon I et al (2023) Thrombectomy with or without intravenous thrombolytics in basilar artery occlusion. Ann Neurol. https://doi.org/10.1002/ana.26720

    Article  PubMed  Google Scholar 

  48. Kaneko J, Ota T, Tagami T, Unemoto K, Shigeta K, Amano T et al (2019) Endovascular treatment of acute basilar artery occlusion: tama-registry of acute thrombectomy (treat) study. J Neurol Sci 401:29–33

    PubMed  Google Scholar 

  49. Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring H-P, Trenkler J et al (2015) Mechanical recanalization in basilar artery occlusion: the endostroke study. Ann Neurol 77:415–424

    PubMed  Google Scholar 

  50. Uno J, Kameda K, Otsuji R, Ren N, Nagaoka S, Maeda K et al (2017) Mechanical thrombectomy for acute basilar artery occlusion in early therapeutic time window. Cerebrovasc Dis 44:217–224

    PubMed  Google Scholar 

  51. Knapen R, Pirson FAV, Langezaal LCM, Brouwer J, Majoie C, Emmer BJ et al (2024) Intravenous thrombolysis before endovascular treatment in posterior circulation occlusions: a mr clean registry study. Stroke 10:e022303

    Google Scholar 

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Funding

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Author information

Author notes

  1. Lingyu Cai and Liaoyuan Wang Co-first author.

Authors and Affiliations

  1. Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China

    Lingyu Cai, Yuelu Wu, Shitai Ye, Pengli Tian, Jingjing Chen, Zhongming Qiu, Qifeng Guo & Zhao Dai

  2. The Third District of Air Force Special Service Sanatorium, Hangzhou, 310002, Zhejiang, China

    Liaoyuan Wang

  3. Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia

    Bruce C. V. Campbell & Fana Alemseged

  4. Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA

    Mohamad Abdalkader & Thanh N. Nguyen

  5. University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Johannes Kaesmacher

  6. Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany

    Volker Puetz

  7. Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany

    Simon Nagel

  8. Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland

    Daniel Strbian

  9. Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands

    Robrecht R. M. M. Knapen

  10. Department of Neurology, The Stroke Center, Xuanwu Hospital of Capital Medical University, Beijing, China

    Chuanhui Li

  11. Community Health Service Center of Sandun Town, Hangzhou, China

    Ruitian Li

  12. Department of Neurology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China

    Wei Hu

  13. Department of Neurology, St. Antonius Hospital, Nieuwegein, Netherlands

    Wouter J. Schonewille

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  1. Lingyu Cai
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  4. Yuelu Wu
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Correspondence to Qifeng Guo or Zhao Dai.

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Since the present manuscript is related to a systematic review and meta-analysis, ethical approval is not required.

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Cai, L., Wang, L., Campbell, B.C.V. et al. Endovascular thrombectomy with versus without intravenous thrombolysis in patients with acute basilar artery occlusion: a systematic review and meta-analysis. J Neurol 271, 3039–3049 (2024). https://doi.org/10.1007/s00415-024-12353-w

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