Contributing countries, centers and center coordinators

Objective: To test the hypothesis that intravenous thrombolysis (IVT)
treatment prior to endovascular thrombectomy (EVT) is associated with
better outcomes in patients with anterior circulation large artery
occlusion (LAO) stroke, we examined a large real-world database, the
SITS-International Stroke Thrombectomy Register (SITS-ISTR). Methods: We
identified centers recording ³10 consecutive patients in the SITS-ISTR,
with at least 70% available modified Rankin Scale (mRS) scores at 3 months
during 2014-19. We defined LAO as intracranial internal carotid artery,
first and second segment of middle cerebral artery and first segment of
anterior cerebral artery. Main outcomes were functional independence (mRS
0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH)
per modified SITS-MOST. We performed propensity score matched (PSM) and
multivariable logistic regression analyses. Results: Of 6350 patients from
42 centers, 3944 (62.1%) received IVT. IVT+EVT treated patients had less
frequent atrial fibrillation, ongoing anticoagulation, previous stroke,
heart failure and pre-stroke disability. PSM analysis showed that IVT+EVT
patients had a higher rate of functional independence than EVT alone
patients (46.4% vs. 40.3%, p<0.001) and a lower rate of death at 3
months (20.3% vs. 23.3%, p=0.035). SICH rates (3.5% vs. 3.0%, p= 0.42)
were similar in both groups. Multivariate adjustment yielded results
consistent with PSM. Interpretation: Pretreatment with IVT was associated
with favorable outcomes in EVT-treated LAO stroke in the SITS Thrombectomy
Registry. These findings, while indicative of international routine
clinical practice, are limited by observational design, unmeasured
confounding and possible residual confounding by indication.
Classification of Evidence: This study provides Class II evidence that IVT
prior to EVT increases the probability of functional independence at 3
months compared to EVT alone.