Lit Matters 2: Lytics Before Transfer for Thrombectomy?

Large vessel occlusion stroke at a primary stroke center creates a different thrombolysis decision than direct presentation to a thrombectomy-capable center. For transfer patients, the key question is whether IV thrombolysis before endovascular therapy improves 90-day outcomes without raising symptomatic intracranial hemorrhage.

Lytics Before Transfer for LVO

• Drip and ship framing: Primary stroke center patients with LVO are not the same as direct-to-CSC thrombectomy patients, so bypass-lysis trials should not be casually extrapolated to transfer decisions.
• Early reperfusion signal: Systemic thrombolysis can reperfuse a meaningful minority of LVOs before arrival for thrombectomy, roughly 10% to 20%, which is the physiologic argument for treating early.
• Observed outcome benefit: Across six studies, IV thrombolysis before transfer was associated with better 90-day functional outcomes, including an odds ratio of 1.7 for excellent outcome on mRS 0 to 1.
• Safety signal on hemorrhage: Symptomatic intracranial hemorrhage did not appear higher with lytics before transfer, an important finding when the major practical objection is bleeding risk.
• Bias and uncertainty: The evidence base is thin and observational, with moderate overall bias and several severely confounded studies. We get into why the primary outcome signal is shakier than the headline suggests in the episode.
• Alteplase versus tenecteplase: The included studies used alteplase, so any enthusiasm about tenecteplase's easier administration and possible recanalization advantage remains an open extrapolation rather than proven here.