Does thrombolysis add value to thrombectomy for acute ischaemic stroke?

The first reperfusion therapy shown to improve the outcomes of patients with acute ischaemic stroke, and become standard medical care, was intravenous thrombolysis with alteplase administered within 4·5 h of symptom onset. 1 Emberson J Lees KR Lyden P et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014; 384: 1929-1935 Summary Full Text Full Text PDF PubMed Scopus (1735) Google Scholar The second reperfusion therapy to improve outcomes in patients with proximal anterior circulation artery occlusion compared with standard care was endovascular treatment with thrombectomy within 12 h of stroke onset. 2 Goyal M Menon BK van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387: 1723-1731 Summary Full Text Full Text PDF PubMed Google Scholar Most participants in the randomised controlled trials (RCTs) of endovascular treatment with thrombectomy versus control (ie, no endovascular thrombectomy) received alteplase as part of background standard care, but 15% of participants did not receive alteplase due to ineligibility. 2 Goyal M Menon BK van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387: 1723-1731 Summary Full Text Full Text PDF PubMed Google Scholar Subgroup analyses showed no heterogeneity of the effect of thrombectomy in those who received, and did not receive, alteplase (pinteraction=0·43). 2 Goyal M Menon BK van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387: 1723-1731 Summary Full Text Full Text PDF PubMed Google Scholar These analyses resulted in the hypothesis that alteplase might not add value when administered before thrombectomy. Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trialsWe did not establish non-inferiority of endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment in patients presenting directly at endovascular treatment centres. Further research could focus on cost-effectiveness analysis and on individualised decisions when patient characteristics, medication shortages, or delays are expected to offset a potential benefit of administering intravenous thrombolysis before endovascular treatment. Full-Text PDF