I’ve been of the general opinion that, no, thrombolytics are of low utility prior to endovascular intervention for stroke. The typical candidate for endovascular intervention has a clot in a large vessel. Thrombolytics are overwhelmingly ineffective at treating such lesions, hence, the entire foundational need for endovascular intervention. Then, absent indication creep, the patients for whom endovascular intervention is intended are those with salvageable tissue as resulting from excellent collateral circulation – i.e., the sort of patients for whom the “time is brain” mantra does not strictly apply. Therefore, thrombolytics prior to the definitive procedure are effectively low-value, and deplete the fibrinogen likely needed to reduce serious procedural adverse events.
But, this is just opinion – useful evidence is profoundly lacking.
This article, unfortunately, does not add much to the current body of evidence. These authors present a post-hoc analysis from the ASTER trial, which tested clot aspiration versus stent retrieval. As is typical for these types of trials, those who arrived within 4.5 hours of symptom onset were treated with thrombolytics prior to their procedure, while others were excluded as “outside the window”. There were 381 patients here, 250 of whom were eligible for thrombolytic therapy. These authors pull out all the stops with regard to data analysis, breaking down their outcomes by procedural attempts, reperfusion, complications, clinical outcomes, and hemorrhagic complications. Then, they further generate forest plots for adjusted outcomes depending on the arm of the trial – aspiration or stent retriever.
And, after all this, it’s still just a retrospective data dredge for meaningless signals replete with unmeasured confounders and selection bias. The patients who received thrombolysis initially are different than those who did not, full stop – and no multivariate regression can reliably produce precise estimates of their likely outcomes. I could have told you “we need a prospective trial design” to shed further light on this question, arriving at the same conclusion in six words, rather than in these seven pages.
“Mechanical Thrombectomy Outcomes With or Without Intravenous Thrombolysis Insight From the ASTER Randomized Trial”
https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.021500