Late-window large-vessel stroke: thrombectomy carries the benefit

Design

Bayesian network meta-analysis of randomised trials

Population

8 trials in confirmed large-vessel or basilar occlusion treated 4.5–24 hours after onset

Primary outcome

Functional independence (mRS 0–2) at 90 days

Effect

Thrombectomy vs medical care OR 2.93 (95% CrI 1.40–6.53); bridging vs thrombectomy OR 1.10 (0.34–3.52)

This Bayesian network meta-analysis included 15 randomised trials of reperfusion given 4.5 to 24 hours after onset or last known well. Its main analysis used the eight trials that required confirmed intracranial large-vessel or basilar occlusion on imaging.

Compared with best medical care, thrombectomy improved functional independence at 90 days (OR 2.93, 95% credible interval 1.40–6.53) and reduced mortality (OR 0.71), at the cost of more symptomatic intracranial haemorrhage (OR 2.65). Adding tenecteplase before thrombectomy gave estimates that leaned favourable but were wide (OR 1.10, 0.34–3.52). Tenecteplase alone showed no clear benefit over medical care in this population.

For a patient with an imaging-confirmed occlusion in the late window, getting to thrombectomy is what the evidence supports. Whether to bridge with tenecteplase in this window remains open, and transfer should not wait on that decision.

• Image for large-vessel occlusion in every candidate presenting 4.5 to 24 hours after onset.
• Refer confirmed occlusions for thrombectomy without delay.
• Do not delay transfer to give or decide on bridging tenecteplase in this window.
• Warn families about the higher risk of symptomatic haemorrhage with thrombectomy.

Why it matters

In the late window, time spent on thrombolysis decisions may be time taken from thrombectomy.

Don't overread it

Network comparisons are indirect; only two trials compared bridging with thrombectomy alone head to head.

The statistics, in plain English

A credible interval is the Bayesian version of a confidence interval. For thrombectomy, the interval for functional independence sits entirely above 1, so benefit is likely. For tenecteplase plus thrombectomy, it runs from 0.34 to 3.52, which means the data cannot tell whether bridging helps, harms or does nothing.

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