A Moving Target? The Fate of Large Vessel Occlusion Strokes Pretreated with Intravenous Tissue Plasminogen Activator in the Era of Mechanical Thrombectomy.

BACKGROUND

Although still recommended, using intravenous tissue plasminogen activator (IV-tPA) for large vessel occlusions (LVOs) has been questioned in the era of mechanical thrombectomy (MT). We sought to determine the impact of IV-tPA if used before MT.

METHODS

We used a single-institution, prospectively maintained stroke database from July 2017 through June 2019. All patients undergoing MT with or without IV-tPA treatment for LVO with pretreatment computed tomography angiography (CTA) head and neck were included. We compared the initial CTA images of clot location and morphology to the angiographic findings visualized on the first injection before mechanical intervention.

RESULTS

Eighty patients were included. About a third (33%) received IV-tPA before thrombectomy. Among patients receiving IV-tPA, significantly more, 29% versus 5.6% without IV-tPA, experienced distal clot migration or changes in morphology between first CTA acquisition and first angiographic run before thrombectomy (P = 0.006). On logistic regression IV-tPA was the only significant predictor of clot migration (P = 0.024). Of note, clot migration due to IV-tPA use was not associated with superior recanalization rates or outcomes in this analysis (P = 0.27). Original site clot resolution was noted in 8% (2/24) of patients who received IV-tPA; however, distal M4/5 embolic cutoffs were noted in both patients.

CONCLUSIONS

IV-tPA administration for LVO has a low rate of primary recanalization with risk of distal embolic phenomenon often still requiring MT. No significant changes in patient outcomes were noted in this study due to clot migration. Larger studies will be necessary to determine if IV-tPA plus MT truly benefits entire clot removal versus MT alone.