WSC 2025 | IV thrombolysis plus endovascular treatment versus endovascular alone in carotid tandem lesions

This is part of the IRIS collaboration, which is an individual participant data meta-analysis of six large randomized clinical trials that compare endovascular treatment alone versus the conventional combination of intravenous thrombolysis with endovascular treatment. The results have been published already and have been discussed before, but in this sub-study what we looked at is what is the effect of the addition of intravenous thrombolysis for patients that actually have a carotid tandem lesion. And that is a very important question you saw during the WSO conference. We had a series of debates on that and that is a topic of a lot of interest. There are a series of randomized clinical trials that we expect to have ready in the coming months or next year. And among the clinicians, the treating physicians, it’s quite common to take the presence of a carotid tandem lesion as a factor in deciding on intravenous thrombolysis. So there is an important survey done with neurointerventions and stroke neurologists that are showing up to 30% of those treating physicians. They prefer to skip intravenous thrombolysis if the patient has a carotid tandem lesion because they think, well, I might need to place a carotid stenting, and if I do need, I might need additional antithrombotic medication. And if I give intravenous thrombolysis for this patient combined with those antithrombotics, maybe the risk of bleeding will be too high. So we looked at that in our population, which are patients randomized to either treatment. What we saw is that in the presence of a carotid tandem lesion, patients that were randomized to treatment, either with endovascular treatment alone or intravenous thrombolysis with endovascular treatment, they had similar outcomes. So in patients with a carotid tandem lesion, there is no real strong reason to skip intravenous thrombolysis if you would otherwise give it to these patients. Of course, the main question is not patients with a carotid tandem lesion, but patients who actually receive acute carotid stenting because in these patients, you might have the higher risk of bleeding. But we also see similar results in this population. And we’re also happy that a couple of days ago, we published a secondary study of that population showing that the effect of acute stenting is associated with better outcomes in patients with carotid tandem lesions. And that, again, regardless of the patients being treated with intravenous thrombolysis or not before the thrombectomy. So we’re happy with that and we are looking forward to the result of the randomized clinical trials that should be coming soon, especially cases like CASES, TITAN, EASI-TOC, START, and PICASSO.

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