Intravenous thrombolysis before endovascular treatment in patients with tandem lesion stroke: A systematic review of safety and efficacy

Wu, Xinting^1,#; Wang, Min^2,#; Nie, Wenhong³; Jiang, Wei³; Hao, Huang³; Xu, Guanghui³; Hu, Qi³; Zhou, Hui³;Huang, Xiaolong^3,*;Qiu, Xichenhui^4,5,*

1Department of Anesthesia, Guang’an People’s Hospital, Guang’an, Sichuan Province, China

2Department of Neurosurgery, Guang’an People’s Hospital, Guang’an, Sichuan Province, China

3Department of Neurosurgery, Guang’an People’s Hospital, Guang’an, Sichuan Province, China

4Medical School, Shenzhen University, Shenzhen, China

5Rory Meyers College of Nursing, New York University, New York, NY, USA

*Correspondence to: Xiaolong Huang, MD, cmuxiaolong@163.com; Xichenhui Qiu, PhD, qiuxichenhui@seu.edu.cn.

#Both authors contributed equally to this work and share first authorship.

Funding:This study was funded by Guangdong Science and Technology Programs Youth Fund, No. 2022A1515110777 (to XQ), Starting Fund of Top-Level Talents of Shenzhen, No. 000514 (to XQ) and National Natural Science Foundation of China (NSFC) Youth Fund, No. 72404193 (to XQ).

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0.

Advanced Technology in Neuroscience 3(1):p 1-6, Jan–Mar 2026. | DOI: 10.4103/ATN.ATN-D-25-00011

Abstract

Endovascular thrombectomy is widely recognized as the standard treatment for acute ischemic stroke caused by large vessel occlusion. However, the efficacy and safety of intravenous thrombolysis before endovascular thrombectomy in acute ischemic stroke patients with tandem lesions remain a subject of ongoing debate. Tandem lesions are characterized by concurrent intracranial large vessel occlusion and extracranial internal carotid artery stenosis or occlusion. The dual pathology of tandem lesions complicates therapeutic strategies. Herein, a systemic review is conducted to assess the efficacy and safety of intravenous thrombolysis combined with endovascular thrombectomy versus direct endovascular thrombectomy alone in patients with tandem lesions.Relevant literature was searched in PubMed, Embase, and the Cochrane Library from their inception to May 1, 2024. Five observational studies involving 1445 patients were included. Primary outcomes included 3-month clinical outcomes, reperfusion success rate, incidence of asymptomatic cerebral hemorrhage, and mortality rate.Compared with direct endovascular thrombectomy alone, intravenous thrombolysis plus endovascular thrombectomy significantly improved 3-month clinical outcomes (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.16–1.95), elevated reperfusion success rate (OR = 1.60, 95% CI: 1.21–2.11), and reduced 3-month mortality (OR = 0.69, 95% CI: 0.52–0.93). However, no significant difference was observed in the incidence of asymptomatic cerebral hemorrhage (OR = 0.93, 95% CI: 0.66–1.31) between the two treatment modalities. Additionally, three studies compared the therapeutic efficacy of tenecteplase and alteplase, revealing no significant differences in 3-month clinical outcomes, reperfusion success rates, incidence of asymptomatic cerebral hemorrhage, and mortality between the two thrombolytic agents. Subgroup analyses suggested that the benefits of intravenous thrombolysis plus endovascular thrombectomy were consistent across different patient populations, including age, baseline stroke severity, and time-to-treatment intervals.Intravenous thrombolysis combined with endovascular thrombectomy significantly improves clinical outcomes and reduces mortality in acute ischemic stroke patients with tandem lesions, without increasing the risk of asymptomatic cerebral hemorrhage. However, the current evidence is primarily derived from observational studies, which may involve selection bias and confounding factors. Further randomized controlled trials are warranted to validate these results and to explore the impact of patient-specific and surgical factors on clinical outcomes. This study was conducted in accordance with the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) statement, and the study protocol was registered with PROSPERO (registration No. CRD42024570536).

摘要

血管内血栓切除术是治疗大血管闭塞引起的急性缺血性脑卒中的标准方法。然而，对于伴有串联病变的患者，血管内血栓切除术前进行静脉溶栓的有效性和安全性仍存在争议。串联病变的特点是颅内大血管闭塞和颅外颈内动脉狭窄或闭塞并存，这种双重病理特征使治疗策略更加复杂。文章通过系统综述的方法评估了静脉溶栓联合血管内血栓切除术与单独直接血管内血栓切除术在串联病变患者中的疗效和安全性。研究纳入了PubMed、Embase和Cochrane图书馆中的相关文献，最终筛选出5项观察性研究，共涉及1,445例患者。主要评估指标包括3个月临床预后、再灌注成功率、无症状性脑出血发生率和死亡率。研究结果显示，与单独直接血管内血栓切除术相比，静脉溶栓联合血管内血栓切除术显著改善了患者的3个月临床预后（OR = 1.51，95% CI：1.16-1.95），提高了再灌注成功率（OR = 1.60，95% CI：1.21-2.11），并降低了3个月死亡率（OR = 0.69，95% CI：0.52-0.93）。两种治疗方式的无症状性脑出血发生率无显著差异（OR = 0.93，95% CI：0.66-1.31）。此外，3项研究比较了替奈普酶和阿替普酶的疗效，结果显示两种溶栓药物在临床疗效、再灌注成功率、无症状性脑出血发生率和死亡率方面均无显著差异。亚组分析表明，静脉溶栓联合血管内血栓切除术的益处在不同患者人群中具有一致性，包括不同年龄、基线卒中严重程度和治疗间隔时间的患者。研究结论指出，静脉溶栓联合血管内血栓切除术可显著改善串联病变患者的临床预后和生存率，且不会增加无症状性脑出血风险。然而，当前证据主要来自观察性研究，可能存在选择偏差和混杂因素。未来需要开展随机对照试验以验证这些结果，并进一步探讨特定患者和手术因素对治疗效果的影响。本研究依据系统评价和荟萃分析的首选报告项目（PRISMA）声明开展，22且研究方案已在PROSPERO注册（注册号：CRD42024570536）。