Lit Matters #3: EVT Alone vs Lytics + EVT for Stroke

Direct-to-thrombectomy-center anterior-circulation stroke is not yet a settled case for skipping IV alteplase before endovascular therapy. MR CLEAN–NO IV found EVT alone was neither superior to bridging thrombolysis plus EVT nor proven noninferior, keeping alteplase in the conversation for eligible patients.

EVT Alone vs Bridging Thrombolysis

• Direct-center stroke population: The trial enrolled patients presenting straight to EVT-capable stroke centers with proximal anterior-circulation occlusion within 4.5 hours, so the findings apply best to thrombectomy-ready systems rather than transfer-in settings.
• Primary disability outcome: Functional recovery favored neither shortcut nor clear equivalence: median 90-day modified Rankin score was 3 with EVT alone versus 2 with alteplase plus EVT, and EVT alone did not show superiority.
• Noninferiority not established: The key practice point is not that EVT alone failed, but that it was not proven close enough to alteplase plus EVT to be considered an acceptable substitute. We get into why superiority and noninferiority answer different bedside questions in the episode.
• Reperfusion signal: Successful reperfusion numerically trended higher with alteplase plus EVT, reinforcing the biologic case that bridging thrombolysis may still help before clot retrieval even when thrombectomy is available.
• Safety and mortality signal: Symptomatic intracranial hemorrhage was similar at about 5% in both groups, while 90-day mortality was numerically higher with EVT alone, a cautionary pattern even without a definitive difference.
• What this changes now: For alteplase-eligible patients already at a comprehensive stroke center, this study does not support routinely skipping lytics before thrombectomy, though the unresolved exceptions are where the nuance lives in the chapter.