Efficacy and safety of bridging therapy and thrombectomy alone in patients with large infarcts of unrestricted size: LASTE trial post hoc analysis

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BACKGROUND: Endovascular thrombectomy (EVT) is now the standard treatment for patients with large cerebral infarcts. However, the benefit of intravenous thrombolysis before EVT (IVT+EVT) in this setting is uncertain. METHODS: We conducted a post hoc analysis of the Large Stroke Therapy Evaluation (LASTE) trial, which randomized patients with large infarcts (Alberta stroke program early CT score (ASPECTS) ≤5) to EVT plus medical care or medical care alone. Among those assigned to EVT, patients were divided into two groups: IVT+EVT and EVT alone. The main outcome was the shift analysis of the 3 month modified Rankin Scale (mRS) score. Safety outcomes included parenchymal hemorrhage (PH) and symptomatic intracranial hemorrhage (sICH). RESULTS: 27.9%, p<0.001) and shorter onset-to-imaging time (median 148 (91-280) vs 200 (123-311); P=0.024). Both groups had similar rates of ASPECTS 0-2 (50.9% vs 55.8%; P=0.56). There was no significant difference in 3 month functional outcome between IVT+EVT and EVT alone (generalized OR 1.22 (95% CI 0.85 to 1.74); P=0.28) or sICH (RR 1.72 (95% CI 0.65 to 4.48); P=0.27). Pre-EVT recanalization was higher in the IVT+EVT group (RR 15.1 (95% CI 1.9 to 117.9); P<0.001). Mortality rates did not differ significantly. DISCUSSION: In patients with very large infarcts, IVT+EVT was not associated with better functional outcome than EVT alone, despite higher pre-EVT recanalization rates. Safety outcomes were comparable. Randomized trials are warranted to clarify the role of IVT in this high-risk population. TRIAL REGISTRATION NUMBER: NCT03811769.

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