Thrombolysis before transfer for thrombectomy tracked with better 90-day function

Design

Systematic review and meta-analysis of observational studies

Population

16 studies of LVO stroke patients transferred from primary to comprehensive stroke centres

Primary outcome

Excellent functional outcome (mRS 0–1) at 90 days

Effect

Adjusted OR 1.47 (1.19–1.81); mortality aOR 0.64 (0.49–0.84); sICH OR 0.75 (0.50–1.11)

When a patient with large-vessel occlusion stroke arrives at a hospital that cannot do thrombectomy, the question is whether to give intravenous thrombolysis before transfer or send them straight on. A meta-analysis in the Journal of Neurology (28 September) pooled 16 observational studies of exactly this drip-and-ship situation.

Pre-transfer thrombolysis was associated with more excellent outcomes at 90 days (mRS 0–1: adjusted OR 1.47, 95% CI 1.19 to 1.81), more good outcomes (adjusted OR 1.61), recanalisation during transfer in far more patients (adjusted OR 8.06) and lower 90-day mortality (adjusted OR 0.64). Symptomatic intracranial haemorrhage was not increased (OR 0.75, 0.50 to 1.11).

These are observational comparisons, and patients who were not thrombolysed often had reasons — later arrival, contraindications — that also worsen outcome, which adjustment only partly removes. But the direction is consistent and matches current guidance to give thrombolysis to eligible patients without waiting for thrombectomy. For India, where transfer distances and delays are often long, the case for thrombolysing before the ambulance leaves is, if anything, stronger.

• Continue to give intravenous thrombolysis to eligible patients before transfer for thrombectomy, as guidance advises.
• Start the transfer process in parallel with thrombolysis, not after it.
• Pre-transfer thrombolysis was not associated with more symptomatic haemorrhage.
• Recanalisation during transfer may make thrombectomy unnecessary; reassess on arrival.

Why it matters

It supports current guidance against skipping thrombolysis when thrombectomy is planned elsewhere.

Don't overread it

All 16 studies were observational; randomised trials of bridging thrombolysis in direct-to-centre patients gave more mixed results.

The statistics, in plain English

An adjusted odds ratio of 1.47 means the odds of an excellent outcome were about half as high again with thrombolysis, after accounting for measured differences between groups. Unmeasured differences — why some patients were not thrombolysed — can still bias the result. The haemorrhage interval (0.50 to 1.11) includes no difference, which is reassuring.

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