Standard Antiplatelet Therapy Versus Thrombolysis in Acute Spontaneous Spinal Cord Infarction: A Propensity Score–Matched Analysis

BACKGROUND: Spinal cord infarction (SCI) is a rare stroke subtype with no established acute treatment guidelines. Thrombolytic therapy has been used empirically based on extrapolation from cerebral stroke protocols, but comparative effectiveness data are lacking. We compared outcomes between standard care and thrombolysis in acute spontaneous SCI. METHODS: This retrospective cohort study used data from the TriNetX Global Collaborative Network. Adult patients with acute SCI ( International Classification of Diseases , Tenth Revision, Clinical Modification code G95.11) were divided into the standard care group (antiplatelet therapy within 48 hours) or the thrombolysis group (alteplase or tenecteplase). Patients who underwent aortic repair procedures were excluded. Propensity score matching (1:1) balanced 68 covariates. The prespecified primary outcome was all-cause mortality; readmission and rehabilitation utilization at 180 days were secondary exploratory outcomes. E values were calculated for the significant association. RESULTS: Of the 965 patients in the standard care cohort and 103 in the thrombolysis cohort, 96 patients in each cohort remained after matching. Standard care was associated with significantly lower mortality (13.5% versus 29.2%; hazard ratio, 0.423 [95% CI, 0.219–0.817]; P =0.008); 180-day survival was 84.27% versus 68.69% (log-rank P =0.008), with an E value of 4.16. Readmission (14.6% versus 16.7%; P =0.669) and rehabilitation utilization (43.8% versus 49.0%; P =0.507) did not differ. The mortality association was consistent in direction across 3 sensitivity analyses. CONCLUSIONS: In spontaneous SCI, standard care was associated with significantly lower mortality than thrombolysis, without significant differences in readmission rates or rehabilitation utilization. These hypothesis-generating findings raise concerns about off-label thrombolytic use in SCI and support consideration of conservative management until higher-quality evidence emerges.