Endovascular thrombectomy with and without preceding thrombolysis in posterior circulation stroke – insights from STAR

Background: Multiple randomized trials could not establish the non-inferiority of endovascular thrombectomy (EVT) alone without preceding intravenous thrombolysis (IVT) or superiority of IVT followed by EVT in anterior circulation large vessel occlusion (LVO) stroke. The role of prior IVT in posterior circulation LVO remains controversial. Methods: In this multicenter, retrospective study, stroke patients with LVO in the posterior circulation who received EVT alone or with IVT were selected from the stroke thrombectomy and aneurysm registry (STAR) between 2013 to 2022. Effects of IVT followed by thrombectomy on favorable functional outcome (defined as modified Rankin scale ? 3 at 90 days) and safety were investigated using multivariable logistic and linear regression models. Results: Of the 588 included patients, 67 % (n = 394) were treated with EVT alone and 29% (n = 170) with EVT after IVT and 4% (n = 24) have missing values on this variable. Controlling for multiple confounding factors, IVT was not associated with a higher likelihood of favorable functional outcome at 90 days (odds ratio 1.04, 95 % CI 0.52-2.09, p = 0.901). Thrombectomy alone did not show any safety advantages compared with those receiving IVT. Conclusions: Similar functional outcomes and complication rates were seen in patients with posterior circulation LVO treated with EVT alone vs EVT after IVT. Further prospective studies are required to determine the utility of IVT in posterior circulation stroke, especially in patients being directly admitted to thrombectomy centers. ### Competing Interest Statement Dr Arthur: personal fees from Balt, Cerenovus, Medtronic, Microvention, Penumbra, Perfuze, Siemens, and Stryker; consulting fees from Arsenal, Balt, Johnson & Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, and Stryker; and being a shareholder at Bendit, Cerebrotech, Magneto, Vastrax, and VizAI outside the submitted work. Dr Jabbour: consulting fees from Balt, Cerus Endovascular, MicroVention, and Medtronic outside the submitted work. Dr Kan: personal fees from Stryker Neurovascular Consulting, Imperative Care Consulting, Cerenovus Consulting, and Microvention Consulting outside the submitted work. Dr Levitt: unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers, and Metis Innovative; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery. Dr Mascitelli: consulting fees from Stryker outside the submitted work. Dr Osbun: personal fees from Medtronic, Stryker, Terumo, Microvention, Penumbra, and InNeuroCo outside the submitted work. Dr Polifka: consulting fees from Stryker and Depuy Synthes outside the submitted work. Dr Rai: personal fees from Stryker Neurovascular and Cerenovus outside the submitted work. Dr Romano: consulting fees from Penumbra INC, Microvention Europe, Balt International, and Balt Italy outside the submitted work. Dr Spiotta: Stroke Thrombectomy and Aneurysm Registry financial and nonfinancial support from RapidAI, Medtronic, Stryker Neurovascular, Penumbra, and Avail; research grants from Medtronic, Stryker Neurovascular, and Penumbra; and consulting services from Stryker Neurovascular, Penumbra, RapidAI, and Terumo outside the submitted work. Dr Starke: grants from the National Institutes of Health; and consulting fees from Medtronic, Penumbra, Cerenovus, Balt, InNeuroCo, Optimize Vascular, and Abbott outside the submitted work. Dr Yoshimura: personal fees from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics, Terumo, and Biomedical Solutions during the conduct of the study; personal fees from Boehringer-Ingelheim, Daiichi Sankyo, Bayer, and Bristol-Myers Squibb outside the submitted work. No other disclosures were reported. ### Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by institutional review boards at each study center, and there was no need for written informed consent given the retrospective design of the study. The study follows the 'Strengthening the Reporting of Observational Studies in Epidemiology' statement. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available from the corresponding author upon reasonable request.