The effect of intravenous thrombolysis in stroke patients with unsuccessful thrombectomy

Sameh Samir Elawady; Rahim Abo Kasem; Hidetoshi Matsukawa; Conor Cunningham; Mohamed Mahdi Sowlat; Noah Lee Nawabi; Atakan Orscelik; Joshua M Venegas; Julio Isidor; Hasna Loulida; Ilko Maier; Pascal Jabbour; Joon-Tae Kim; Stacey Quintero Wolfe; Ansaar Rai; Robert M Starke; Marios-Nikos Psychogios; Edgar A Samaniego; Nitin Goyal; Shinichi Yoshimura; Hugo Cuellar; Brian Howard; Ali Alawieh; Ali Alaraj; Mohamad Ezzeldin; Daniele G Romano; Omar Tanweer; Justin Mascitelli; Isabel Fragata; Adam Polifka; Fazeel Siddiqui; Joshua Osbun; Ramesh Grandhi; Roberto Crosa; Charles Matouk; Min S Park; Michael R Levitt; Waleed Brinjikji; Mark Moss; Ergun Daglioglu; Richard Williamson Jr; Pedro Navia; Peter Kan; Reade De Leacy; Shakeel Chowdhry; David J Altschul; Alejandro M Spiotta; Sami Al Kasab

doi:10.1177/15910199241279009

The effect of intravenous thrombolysis in stroke patients with unsuccessful thrombectomy

Interv Neuroradiol. 2024 Sep 12:15910199241279009. doi: 10.1177/15910199241279009. Online ahead of print.

Authors

Sameh Samir Elawady^{1

2}, Rahim Abo Kasem^{1

2}, Hidetoshi Matsukawa^{1

3}, Conor Cunningham¹, Mohamed Mahdi Sowlat¹, Noah Lee Nawabi¹, Atakan Orscelik⁴, Joshua M Venegas¹, Julio Isidor¹, Hasna Loulida¹, Ilko Maier⁵, Pascal Jabbour⁶, Joon-Tae Kim⁷, Stacey Quintero Wolfe⁸, Ansaar Rai⁹, Robert M Starke¹⁰, Marios-Nikos Psychogios¹¹, Edgar A Samaniego¹², Nitin Goyal¹³, Shinichi Yoshimura⁴, Hugo Cuellar¹⁴, Brian Howard¹⁵, Ali Alawieh¹⁵, Ali Alaraj¹⁶, Mohamad Ezzeldin¹⁷, Daniele G Romano¹⁸, Omar Tanweer¹⁹, Justin Mascitelli²⁰, Isabel Fragata²¹, Adam Polifka²², Fazeel Siddiqui²³, Joshua Osbun²⁴, Ramesh Grandhi²⁵, Roberto Crosa²⁶, Charles Matouk²⁷, Min S Park²⁸, Michael R Levitt²⁹, Waleed Brinjikji³⁰, Mark Moss³¹, Ergun Daglioglu³², Richard Williamson Jr³³, Pedro Navia³⁴, Peter Kan³⁵, Reade De Leacy³⁶, Shakeel Chowdhry³⁷, David J Altschul³⁸, Alejandro M Spiotta^{1

39}, Sami Al Kasab^{1

39}

Affiliations

¹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
² Co-first authors.
³ Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
⁴ Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA.
⁵ Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
⁶ Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
⁷ Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea.
⁸ Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA.
⁹ Department of Radiology, West Virginia School of Medicine, Morgantown, WV, USA.
¹⁰ Department of Neurosurgery, University of Miami Health System, Miami, FL, USA.
¹¹ Department of Interventional and Diagnostical Neuroradiology, University of Basel, Basel, Switzerland.
¹² Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
¹³ Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA.
¹⁴ Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport, LA, USA.
¹⁵ Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA.
¹⁶ Department of Neurosurgery, University of Chicago at Illinois, Chicago, IL, USA.
¹⁷ Department of Clinical Neuroscience, University of Houston, HCA Houston Healthcare Kingwood, Kingwood, TX, USA.
¹⁸ Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerno, Italy.
¹⁹ Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
²⁰ Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
²¹ Department of Neuroradiology, Hospital São José Centro Hospitalar, Lisboa, Portugal.
²² Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
²³ Department of Neuroscience, University of Michigan Health West, Wyoming, MI, USA.
²⁴ Department of Neurological Surgery, Washington University, St Louis, MO, USA.
²⁵ Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA.
²⁶ Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay.
²⁷ Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.
²⁸ Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
²⁹ Department of Neurosurgery, University of Washington, Seattle, WA, USA.
³⁰ Department of Radiology and Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
³¹ Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, AZ, USA.
³² Department of Neurosurgery, Health Science University, Ankara Bilkent City Hospital, Ankara, Turkey.
³³ Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA.
³⁴ Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁵ Department of Neurological Surgery, University of Texas Medical Branch - Galveston, Galveston, TX, USA.
³⁶ Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA.
³⁷ Department of Neurosurgery, NorthShore University Health System, Evanston, IL, USA.
³⁸ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
³⁹ Senior co-authors.

Abstract

Background: The benefit of intravenous thrombolysis (IVT) is well established. We aim to study the benefits of IVT in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) who underwent unsuccessful mechanical thrombectomy (MT).

Methods: We included AIS patients who underwent MT for anterior circulation LVO with failed recanalization (modified treatment in cerebral ischemia [mTICI] score ≤ 2A). Patients who received IVT prior to MT were compared to those who received MT alone. Propensity score matching using demographic, clinical, radiographic and procedural variables was used to match patients with and without IVT. The primary outcome was favorable 90-day good functional outcome (defined as modified Rankin scale of 0-2), and secondary outcomes included intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality.

Results: Totally, 610 AIS patients with unsuccessful MT were included. After propensity matching, 219 patients were identified in each group. Median age was 70 years and 73 years in the IVT + MT and MT alone groups, respectively. In the IVT + MT group, final mTICI scores of 0, 1, and 2A were achieved in 92 (42.0%), 33 (15.1%), and 94 (42.9%) patients, respectively, versus 76 (34.7%), 29 (13.2%), and 114 (52.1%) in the MT alone group. The IVT + MT group had greater odds of 90-day good functional outcome (adjusted odds ratio 2.54, 95% confidence interval 1.53-4.32). There were no significant differences in secondary outcomes.

Conclusions: IVT is associated with improved functional outcomes in AIS patients with LVO despite unsuccessful MT.

Keywords: LVO; Stroke; thrombectomy; thrombolysis.

Abstract

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