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STOP-CAD tPA

Intravenous Thrombolysis in Patients With Cervical Artery Dissection: A Secondary Analysis of the STOP-CAD Study

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Year of Publication: 2024

Authors: Liqi Shu, Favour Akpokiere, Daniel M. Mandel, ..., Mohammad Almajali

Journal: Neurology

Citation: Neurology. 2024;103:e209843. doi:10.1212/WNL.0000000000209843

Link: https://www.neurology.org/doi/10.1212/WNL.0000000000209843

PDF: https://pmc.ncbi.nlm.nih.gov/articles/PM...2024-102152.pdf

Clinical Question

Does IV thrombolysis improve outcomes in patients with spontaneous cervical artery dissection presenting with acute ischemic stroke symptoms?

Study Overview

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

IVT was associated with better 90-day functional outcomes after adjustment
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.

Patients per Arm

512 IVT, 1,141 no IVT

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 (IQR 93–836)

Countries:

Sample Size: 1653

Analysis: Main models: multivariable logistic regression adjusted for age and baseline NIHSS score. Sensitivity analysis: inverse probability of treatment weighting (IPTW) using sex, White race, other races, Hispanic ethnicity, history of diabetes mellitus, presence of occlusive dissection, dissection involving vertebral artery, acute endovascular therapy, and baseline NIHSS score.

Inclusion Criteria

Spontaneous cervical artery dissection
Ischemic stroke presentation within 1 day of acute ischemic stroke symptoms

Exclusion Criteria

Patients with missing functional outcome data (excluded from primary outcome analysis; 90-day mRS available for 1,304 of 1,653)

Baseline Characteristics

Sex - Female: 31.1% (IVT) vs 36.9% (No IVT)

Median Age: 50 (IVT) vs 49 (No IVT)

NIHSS Score: 11 (IQR 5–18) IVT vs 4 (IQR 1–11) No IVT

White Race: 77.0% (IVT) vs 71.1% (No IVT)

Diabetes Mellitus: 6.8% (IVT) vs 11.6% (No IVT)

Vertebral Artery Dissection: 24.4% (IVT) vs 48.7% (No IVT)

Occlusive Dissection: 59.7% (IVT) vs 46.2% (No IVT)

Endovascular Therapy: 61.3% (IVT) vs 22.3% (No IVT)

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	681/890 (76.5%)	305/414 (73.7%)		0.001
Discharge mRS 0–2	Secondary	699/1,097 (63.7%)	283/499 (56.7%)	aOR 1.32	0.028
90-day mRS 0–1	Secondary	510/890 (57.3%)	212/414 (51.2%)	aOR 1.35	0.031
Symptomatic Intracranial Hemorrhage	Adverse	18/1,141 (1.6%)	21/512 (4.1%)	aOR 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

The authors report no targeted funding.

Based on: STOP-CAD tPA (Neurology, 2024)