Introduction: Endovascular therapy including mechanical thrombectomy has revolutionized stroke care in the setting of large vessel occlusion (LVO). Since the publication of the landmark thrombectomy trials, mechanical thrombectomy using stentriever devices has become standard. However, the role of concomitant intra-arterial alteplase (IA-tPA) has not been clearly defined in the literature. This study aimed to define the most effective use of chemical thrombolysis in the post-thrombectomy study era.
Methods: 26 patients with LVO causing ischemic stroke who met endovascular intervention criteria underwent mechanical thrombectomy with or without IA-tPA. When IA-tPA was used, five milligrams were infused at three time points: 1. cervical internal carotid artery catheterization, 2. stentreiver clot engagement, 3. post-recanalization. In all cases, SolitaireTM with PenumbraTM aspiration was used and intravenous tPA was used when indicated.
Results: Eighteen patients received IA-tPA with thrombectomy, while eight underwent thrombectomy alone. In the IA-tPA group, sixteen TICI 3, one TICI 2b, and one TICI 0 were achieved. In the non-IA-tPA group, one TICI 3, five TICI 2b, and two TICI 0 were achieved. Of the IA-tPA and non-IA-tPA groups, 94% and 75% were TICI 2B or 3, respectively. Mean ictus to revascularization time was 305 minutes and mean groin puncture to revascularization was 72 minutes, with insignificant differences between groups. For the IA-tPA and non-IA-tPA groups, the mean presenting NIHSS were 14.7 and 12.6, at discharge were 8.1 and 11.2, and the mean improvement of NIHSS were 9.6 and 8.2, respectively. There was one mortality of the eighteen IA-tPA patients and two mortalities of the eight non-IA-tPA patients.
Conclusions: Concomitant IA-tPA thrombolysis with mechanical thrombectomy is a safe and effective technique for revascularization with potentially synergistic affects. Further investigation into the efficacy of this method and optimal utilization is warranted.
Patient Care: Safety profiles will be outlined to guide when the benefits of intra-arterial tPA during thrombectomy outweigh the risks.
Learning Objectives: To understand the role of intra-arterial thrombolysis use during mechanical thrbombectomy