STOP-CAD tPA
Intravenous Thrombolysis in Patients With Cervical Artery Dissection: A Secondary Analysis of the STOP-CAD Study
Clinical Question
Does IV thrombolysis improve outcomes in patients with spontaneous cervical artery dissection presenting with acute ischemic stroke symptoms?
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.
Design
Study Type: Retrospective observational analysis
Randomization:
Blinding: Unblinded outcome assessment; analysis adjusted for confounding
Enrollment Period: Not specified; registry-based analysis from STOP-CAD
Follow-up Duration: Median 288 days
Countries:
Sample Size: 1653
Analysis: Multivariable and IPTW-adjusted logistic regression; adjusted for age, sex, NIHSS, race, hypertension, diabetes, thrombus, dissection location
Inclusion Criteria
- Spontaneous cervical artery dissection
- Ischemic stroke presentation within 1 day of symptom onset
Exclusion Criteria
- Patients with missing functional outcome data
- Patients receiving both IVT and endovascular therapy on day 0 were excluded from primary analysis
Arms
| Field | IVT | Control |
|---|---|---|
| Intervention | Intravenous thrombolysis (tPA) administered within 1 day of stroke symptoms in CeAD | Supportive care and secondary prevention without IV thrombolysis |
| Duration | Single dose | NA |
Outcomes
| Outcome | Type | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| 90-day functional independence (mRS 0–2) | Primary | 76.5% | 73.7% | 0.001 | |
| Discharge mRS 0–2 | Secondary | 63.7% | 56.7% | 1.32 | 0.028 |
| 90-day mRS 0–1 | Secondary | 57.3% | 51.2% | 1.35 | 0.031 |
| Symptomatic Intracranial Hemorrhage | Adverse | 1.6% | 4.1% | 1.52 | 0.215 |
Subgroup Analysis
IVT benefit most pronounced in patients with NIHSS >5, no intracranial extension, and absence of thrombus. No significant interaction by sex or endovascular therapy.
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.
Funding
No targeted funding; supported by STOP-CAD registry infrastructure
Based on: STOP-CAD tPA (Neurology, 2024)
Authors: Liqi Shu, Favour Akpokiere, Daniel M. Mandel, ..., Mohammad Almajali
Citation: Neurology. 2024;103:e209843. doi:10.1212/WNL.0000000000209843
Content summarized and formatted by NeuroTrials.ai.