Neurology · Medical Literature
Intravenous Thrombolysis Combined With Endovascular Treatment Versus Endovascular Treatment Alone in Acute Ischemic Stroke due to Tandem Lesions: A Systematic Review and Meta-Analysis.
Abstract
For patients suffering from acute ischemic stroke (AIS) brought on by tandem lesions (TL), to compare the safety and efficacy of intravenous thrombolysis (IVT) in conjunction with endovascular therapy (EVT) to EVT alone. Relevant studies published up until October 20, 2024, were found by a systematic assessment of the literature from the PubMed, Embase, and Cochrane databases. Results such as the 90-day modified Rankin Scale (mRS) score, effective recanalization, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality were the main focus of the comparison between IVT plus EVT and EVT alone in patients with TL. A total of 1756 patients from nine studies were included in the final analysis; 976 of these patients were categorized as IVT + EVT group patients, and 780 as EVT alone group patients. The IVT plus EVT group was associated with a higher rate of successful recanalization (modified Thrombolysis in Cerebral Infarction score [mTICI] ≥ 2b/3) (RR = 1.11; 95% CI, 1.04-1.18; p 0.05; I2 = 20%). Furthermore, the 90-day mortality rate was lower for IVT with EVT than for EVT alone (RR = 0.67; 95% CI, 0.52-0.87; p < 0.05; I2 = 0%). IVT + EVT, as opposed to EVT alone, may be correlated with superior functional results at 90 days in AIS patients with TL.
Clinical relevance
Acute ischemic stroke due to tandem lesions — simultaneous intracranial large-vessel occlusion and ipsilateral cervical internal carotid artery stenosis or occlusion — represents a high-stakes, technically complex subgroup for which optimal reperfusion strategy remains debated. Current guidelines do not specifically mandate combined IVT plus EVT in this cohort, leaving clinicians without clear direction. This meta-analysis directly addresses that evidence gap by pooling comparative outcome data from nine studies totaling 1,756 patients.
Key findings
1. Successful recanalization (mTICI ≥2b/3) was significantly higher in the IVT+EVT group versus EVT alone (RR = 1.11; 95% CI, 1.04–1.18; p 0.05; I² = 20%), suggesting that the addition of IVT does not meaningfully increase hemorrhagic risk in this population. 4. Ninety-day mortality was significantly lower in the IVT+EVT group (RR = 0.67; 95% CI, 0.52–0.87; p < 0.05; I² = 0%), corresponding to a 33% relative reduction in mortality risk with no heterogeneity across studies. 5. The meta-analysis included 976 IVT+EVT patients and 780 EVT-alone patients across nine studies retrieved from PubMed, Embase, and Cochrane databases up to October 20, 2024; NNT was not reported in the abstract.
Practice implications
For eligible AIS patients presenting with tandem lesions who meet standard IVT criteria (no absolute contraindications, within the thrombolytic time window), this meta-analysis supports administering IVT prior to or concurrent with EVT rather than proceeding to EVT alone, given the associated improvements in recanalization, functional independence, and 90-day survival without a significant increase in sICH. Clinicians should apply standard IVT eligibility screening rigorously — particularly regarding anticoagulant use, recent surgery, and blood pressure thresholds — as the safety signal is only reassuring within the context of appropriately selected patients. Given that the underlying evidence derives from observational and retrospective studies with inherent selection bias, prospective randomized controlled trials are needed before definitive protocol-level changes are adopted institution-wide.