Résumé
The benefit of IV thrombolysis (IVT) before endovascular therapy (EVT) in acute ischemic stroke patients with basilar artery occlusion (BAO) remains unclear. Most existing studies have focused on patients directly admitted to comprehensive stroke centers (CSCs), where EVT is readily available. Our objective was to evaluate the effectiveness and safety of IVT initiated before interhospital transfer in patients with BAO initially admitted to a primary stroke center (PSC).
We analyzed data from 3 prospectively collected cohorts of patients with BAO transferred from a PSC to a CSC (Rothschild Foundation Hospital, Montpellier University Hospital, Stanford Hospital) for EVT consideration, regardless of whether EVT was ultimately performed. The primary effectiveness outcome was favorable 3-month functional outcome (modified Rankin Scale [mRS] score 0-2). Secondary effectiveness outcomes included excellent outcome (mRS score 0-1) and basilar artery recanalization during transfer (modified Thrombolysis In Cerebral Infarction score 2a-3 at CSC arrival). Safety outcomes included 3-month mortality and any intracerebral hemorrhage (ICH) on 24-hour imaging. The relationship between outcomes and IVT was assessed using multivariable logistic regression adjusting for relevant confounders.
A total of 230 patients were included (median age, 71 years [interquartile range (IQR) 60-78]; 47% female). Ninety (39%) received IVT before transfer. IVT was mostly withheld because of presentation beyond 4.5 hours (61%) or anticoagulant use (14%). The median NIHSS score at the PSC was 14 (IQR 7-24). In multivariable analyses adjusted for the main confounders, IVT was independently associated with favorable 3-month outcome (39% vs 24%, adjusted odds ratio [aOR] 2.02, 95% CI 1.03-3.97,
= 0.04). Regarding secondary outcomes, IVT was associated with basilar recanalization during transfer (aOR 23.7, 95% CI 6.9-81.3,
< 0.001) while mortality at 90 days (aOR 1.12, 95% CI 0.58-2.18) and any ICH at 24 hours (aOR 1.55, 95% CI 0.77-3.1) did not significantly differ between IVT-treated and non-IVT-treated patients.
In patients with BAO transferred for thrombectomy consideration, IVT before transfer was associated with improved recanalization and functional outcomes, without significant safety concerns. However, IVT was administered in only 39% of patients, suggesting a potential need to broaden IVT eligibility criteria in this setting. These findings require confirmation in future studies, given the limited sample size and observational design.
This study provides Class III evidence that in patients with BAO, administering IVT before hospital transfer for thrombectomy is safe and associated with a favorable functional outcome at 3 months.