Endovascular thrombectomy alone did not consistently differ from IVT+EVT for 90-day mRS shift overall, but was favored in patients with intermediate imaging-clinical discordance (OR 1.40; p=0.04).
Meta-Analysis (n=2,312)
randomized
Yes
Does endovascular thrombectomy alone improve 90-day mRS shift compared to intravenous thrombolysis plus endovascular thrombectomy in patients with anterior-circulation large-vessel occlusion?
EVT alone versus IVT+EVT showed no overall difference in functional outcomes, but EVT alone may be favored in patients with intermediate imaging-clinical discordance.
Abstract Background and aims Whether prior intravenous thrombolysis (IVT) modifies outcomes after endovascular thrombectomy (EVT) remains uncertain. We conducted a one-stage individual participant data meta-analysis of six randomized trials from the Improving Reperfusion Strategies in Ischemic Stroke (IRIS) collaboration to evaluate EVT with versus without IVT across imaging–clinical profiles. Methods Patients with anterior-circulation large-vessel occlusion were randomized to EVT alone or IVT+EVT. Profiles were defined by ASPECTS, NIHSS, and a prespecified simple imaging–clinical equation (ASPECTS + 0.2×NIHSS) reflecting imaging–clinical discordance. The primary outcome was 90-day mRS shift analyzed using mixed-effects ordinal logistic regression with a trial random intercept, adjusted for age, atrial fibrillation, occlusion site, and onset-to-randomization time. Interaction tests evaluated effect heterogeneity across strata. Results Of 2312 randomized patients, 2270 were analyzed (1129 EVT alone). Across ASPECTS strata, EVT alone showed no clear overall advantage, with no significant interaction across ASPECTS or ASPECTS–NIHSS groups. Restricted cubic splines supported two knots (13 and 15) for the equation, defining three strata. Treatment-effect heterogeneity was observed across equation strata (P-interaction=0.04): 0–13 OR 0.99 (95% CI 0.83–1.17), 13–15 OR 1.40 (1.01–1.96; p=0.04), and 15–18 OR 0.81 (0.31–2.11). Conclusions Overall, functional outcomes did not differ consistently between EVT alone and IVT+EVT across ischemic injury or clinical severity profiles. However, patients with intermediate imaging–clinical discordance (equation 13–15) showed a trend favoring EVT alone, suggesting that a simple profile-based approach may help inform rapid, individualized bridging decisions when only limited information is available. Conflict of interest nothing to disclose Table 1 - belongs to Results Table 2 - belongs to Conclusions
Nie et al. (2026) conducted a meta-analysis in anterior-circulation large-vessel occlusion (n=2,312). Endovascular thrombectomy (EVT) alone vs. Intravenous thrombolysis plus endovascular thrombectomy (IVT+EVT) was evaluated on 90-day mRS shift. Endovascular thrombectomy alone did not consistently differ from IVT+EVT for 90-day mRS shift overall, but was favored in patients with intermediate imaging-clinical discordance (OR 1.40; p=0.04).