TOPLINE:
Patients with carotid tandem lesions who received intravenous thrombolysis before endovascular treatment showed similar functional outcomes and haemorrhage risks as those who received endovascular treatment alone. An analysis of 2267 patients with and without tandem lesions revealed no significant difference in the rate of symptomatic haemorrhage between treatment groups in those with tandem lesions.
METHODOLOGY:
- Researchers conducted the Improving Reperfusion Strategies in Acute Ischaemic Stroke (IRIS) individual participant data meta-analysis of six randomised controlled trials comparing intravenous thrombolysis plus endovascular treatment (combined therapy) with endovascular treatment alone in patients with large-vessel occlusion stroke presenting directly at endovascular-capable treatment centres.
- A secondary sub-group analysis of IRIS included 2267 patients, with 340 having carotid tandem lesions (161 received combined therapy and 179 received endovascular treatment alone) and 1927 not having tandem lesions (975 received combined therapy and 952 received endovascular treatment alone).
- Patients assigned to receive combined therapy were administered alteplase at doses of 0.9 mg/kg or 0.6 mg/kg (according to Japanese guidelines) or tenecteplase at 0.25 mg/kg, with one patient receiving urokinase.
- The primary outcome was functional outcome, assessed using the 90-day modified Rankin Scale score.
TAKEAWAY:
- Functional outcomes at 90 days were similar between patients with tandem lesions who received combined therapy and those who received endovascular treatment alone (adjusted common odds ratio [acOR], 1.00; 95% CI, 0.62-1.62); the same trend was observed for patients without tandem lesions (acOR, 1.17; 95% CI, 0.99-1.37).
- Rates of intracranial haemorrhage in patients with tandem lesions were comparable between those who received combined therapy and those who received endovascular treatment alone (acOR, 0.95; 95% CI, 0.59-1.54).
- Patients with tandem lesions who received acute stenting had better outcomes than those who did not receive acute stenting (acOR, 1.59; 95% CI, 1.03-2.46).
- Rates of symptomatic haemorrhage in patients with tandem lesions were also similar between those who received combined therapy and those who received endovascular treatment alone (4% vs 6%; acOR, 0.81; 95% CI, 0.28-2.30).
IN PRACTICE:
“In conclusion, the presence of a carotid tandem lesion should not solely inform the decision to administer or withhold intravenous thrombolysis before endovascular treatment in patients presenting directly to centres capable of providing endovascular treatment. Intravenous thrombolysis plus endovascular treatment was neither superior nor inferior to endovascular treatment alone in patients with carotid tandem lesions,” the authors wrote.
SOURCE:
This study was led by Fabiano Cavalcante, MD, Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands. It was published online in The Lancet Neurology.
LIMITATIONS:
Tandem lesion criteria were defined by individual core laboratories in the included trials, potentially introducing bias. Tandem lesions were defined on the basis of the presence of extracranial carotid stenosis or occlusion on baseline imaging; this approach could have overestimated the prevalence of tandem lesions in trials with information from both CT angiography or MR angiography and digital subtraction angiography. The results were applicable only to patients presenting directly to centres capable of providing endovascular treatment without substantial delay.
DISCLOSURES:
This meta-analysis received support from Stryker, Boehringer Ingelheim, and the Amsterdam University Medical Center. Several authors reported receiving grants or funding from and having other ties with various sources.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
