Endovascular Thrombectomy Alone versus Combined with Intravenous Thrombolysis

Background To date, no randomized trial has directly addressed the question of whether intravenous (IV) tissue plasminogen activator (tPA) improves outcomes in IV tPA-eligible patients who will eventually undergo endovascular therapy (EVT), or whether a direct EVT strategy is equally effective. We performed a systematic review and meta-analysis to compare the efficacy and safety of direct EVT versus endovascular treatment with IV tPA (EVT+IV tPA) in adults with acute ischemic stroke. Methods We performed electronic searches of 6 databases from their inception to January 2017. Data were extracted and analyzed according to predefined clinical endpoints. Results Twelve comparative studies, comprising 1275 patients in the EVT-only arm and 1340 patients in the combined EVT+IV tPA arm, were included. The rates of good functional outcomes (modified Rankin Scale score ≤2) and 90-day mortality were not statistically significantly different between the EVT and EVT+IV tPA arms (44% vs. 48%; odds ratio [OR], 0.80; 95% confidence interval [CI], 0.64–1.002; P  = 0.052 and 20.4% vs. 19.4%, OR 1.19; 95% CI, 0.83–1.71; P  = 0.34, respectively). The rate of symptomatic intracranial hemorrhage also was not significantly different between the EVT and EVT+IV tPA arms (3.7% vs. 3.8%; OR, 0.98; 95% CI, 0.65–1.48; P  = 0.91). There were no between-group differences in the rates of other complications. Conclusions No significant differences between the 2 groups were found in terms of favorable functional outcome, mortality rate, or complications based on contemporary endovascular therapies.