LAUSR

In Response: We thank Katsanos et al for their comments on our article on Endovascular treatment (EVT) in clinical practice in Germany. We fully agree that more detailed real life data on the efficacy and safety of intravenous thrombolysis (IVT) before EVT are of special importance for stroke physicians taking care of patients with large vessel occlusions that are eligible both for systemic and endovascular reperfusion therapies. As suggested, we analyzed the effect of IVT on mortality in our GSR-ET (German Stroke Registry Endovascular Treatment) data, representing 25 German stroke centers. Within our cohort, 1457 of 2610 patients (55.8%) received IVT pretreatment. To account for the potential selection bias in using IVT before EVT, we assessed the effect of IVT on mortality using 3 different models: Model I: unadjusted; Model II: adjusted for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale), intravenous alteplase (yes versus no), infarct size before therapy (ASPECTS [Alberta Stroke Program Early CT Score]), and time from symptom onset to groin puncture, in accordance with the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) data; and model III: adjusted for age, baseline National Institutes of Health Stroke Scale, prior use of anticoagulant medication, prestroke modified Rankin Scale, history of diabetes mellitus, baseline mean arterial blood pressure, time from onset to groin puncture, occlusion location, and interhospital transfer according to Chalos et al. Across all 3 models, we found a significant reduction of mortality in patients receiving pretreatment with IVT compared with EVT alone (model I: 0.63 [0.52–0.75], P=0.00000036, model II: 0.69 [0.50–0.94], P=0.02, model III: 0.63 [0.44–0.91], P=0.013). This is in line with both the hypothesis of a potential beneficial effect from IVT pretreatment and with the results from a recent meta-analysis. The descriptive character of our data limits further analysis of potential underlying reasons. Besides, despite the consistency of the results, residual confounding factors cannot be ruled out. Taken together, these results suggest a reduced mortality for patients receiving IVT before EVT even after adjustment for potential confounders. The efficacy of IVT pretreatment in the GSR-ET requires more comprehensive analysis and discussion beyond the restrictions of a letter. Such analysis is currently being conducted and will be presented separately. At present, several randomized controlled trials are addressing the effects of EVT alone in comparison to EVT combined with IVT. We hope that the results from those randomized controlled trials will help to elucidate the effects of IVT pretreatment in the setting of EVT. Disclosures Dr Fiehler reports grants and personal fees from Acandis, grants and personal fees from Cerenovus, grants and personal fees from Medtronic, grants and personal fees from Microvention, personal fees from Penumbra, personal fees from Route92, and grants and personal fees from Stryker outside the submitted work; he works further as a CEO for Eppdata. Dr Wollenweber reports personal fees from Bayer, personal fees from Boeringer Ingelheim, personal fees from PfizerBMS, and personal fees from Portola outside the submitted work.