Endovascular therapy yields significantly superior outcomes for large vessel occlusions compared with intravenous thrombolysis: is it time to randomize?

Abstract

Background and purpose We compared outcomes between endovascular (EV) therapy and intravenous (IV) thrombolysis in large vessel strokes. Methods 223 patients who had received either IV (n=100) or EV (n=123) therapy were analyzed. Only patients with strokes involving the internal carotid artery terminus (ICA-T, n=45), the middle cerebral artery (M1, n=107) or the bifurcation branches (M2, n=71) were included. The primary endpoint was 3 month outcome based on the modified Rankin Scale (mRS) score, good-outcome defined as mRS ≤2. Results The good outcome was 44.7% in the EV group and 26% in the IV group (p=0.003, OR 2.3, 95% CI 1.3 to 4.1). There was no difference in mortality or hemorrhage. For ICA-T occlusions, the good outcome was 27.6% in the EV and 0% in the IV group (p=0.004); for M1 occlusions, 40.6% in the EV versus 10.5% in the IV group (p=0.0006, OR 5.8, 95% CI 1.9 to 18.2); and for M2 occlusions, 76% in the EV versus 47.8% in the IV group (p=0.01, OR 3.5, 95% CI 1.2 to 10.2). For M1 occlusions, the death rate was 27.5% for the EV compared with 57.9% for the IV group (p=0.002, OR 3.6, 95% CI 1.6 to 8.3) with no difference observed in mortality for ICA-T or M2 occlusions. In the univariate analysis, age, National Institutes of Health Stroke Scale score and occlusion site were significant predictors of outcome and mortality (pConclusions There are significantly higher odds of a favorable outcome with EV compared with IV therapy for large vessel strokes. The data support the rationale of a randomized trial for large vessel occlusions.