STOP-CAD tPA
(2024)Objective
STOP-CAD tPA: To evaluate the efficacy and safety of intravenous thrombolysis (IVT) in patients with cervical artery dissection (CeAD) presenting with acute ischemic stroke symptoms.
Study Summary
• No significant increase in symptomatic ICH with IVT after adjustment
• Benefit most evident in patients with NIHSS >5 and no intracranial extension
Intervention
Retrospective secondary analysis of STOP-CAD registry including 1,653 patients with spontaneous CeAD presenting within 1 day of stroke symptoms. Compared outcomes in those receiving IVT vs. not, with adjustment and IPTW sensitivity analysis.
Inclusion Criteria
• Acute ischemic stroke symptoms within 1 day of spontaneous CeAD diagnosis
Study Design
Arms: IVT vs no IVT
Patients per Arm: 512 IVT, 1,141 no IVT
Outcome
• Symptomatic ICH: aOR 1.52 (95% CI 0.79–2.92, p=0.215)
• IPTW analysis confirmed benefit: aOR 1.85 (95% CI 1.31–2.62)
Bottom Line
In this observational analysis of STOP-CAD data, intravenous thrombolysis was associated with improved 90-day functional outcomes in patients with cervical artery dissection, particularly in those with NIHSS >5 and no intracranial extension, without a statistically significant increase in symptomatic intracranial hemorrhage.
Major Points
- Secondary analysis of 1653 patients with spontaneous CeAD presenting with ischemic stroke symptoms within 1 day.
- 31% received IV thrombolysis, typically with higher baseline NIHSS.
- IVT associated with better 90-day mRS 0–2 (aOR 1.67; 95% CI 1.23–2.28; P=0.001) despite slightly lower crude percentage.
- Symptomatic ICH occurred in 4.1% with IVT vs 1.6% without, but not statistically significant (P=0.215).
- Greatest benefit observed in patients with NIHSS >5 and no intracranial extension.
- Findings supported by both adjusted and IPTW analyses.
Study Design
- Study Type
- Retrospective observational analysis
- Randomization
- No
- Blinding
- Unblinded outcome assessment; analysis adjusted for confounding
- Sample Size
- 1653
- Follow-up
- Median 288 days
Primary Outcome
Definition: 90-day functional independence (mRS 0–2)
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| 76.5% | 73.7% | - (aOR 1.67 (95% CI 1.23–2.28)) | 0.001 |
Limitations & Criticisms
- Retrospective, observational design with risk of indication and selection bias.
- Unblinded outcome assessment could introduce bias.
- Residual confounding despite statistical adjustment.
- Subgroup results should be interpreted cautiously due to limited power.
- Heterogeneity in IVT timing and concurrent treatments.
Citation
Neurology. 2024;103:e209843. doi:10.1212/WNL.0000000000209843