Comparison of combined intravenous and intra-arterial thrombolysis with intravenous thrombolysis alone in stroke patients undergoing mechanical thrombectomy: a propensity-matched analysis

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

doi:10.1136/jnis-2024-021975

Comparison of combined intravenous and intra-arterial thrombolysis with intravenous thrombolysis alone in stroke patients undergoing mechanical thrombectomy: a propensity-matched analysis

J Neurointerv Surg. 2024 Aug 23:jnis-2024-021975. doi: 10.1136/jnis-2024-021975. Online ahead of print.

Authors

Sameh Samir Elawady¹, Rahim Abo Kasem¹, Bhageeradh Mulpur², Conor Cunningham¹, Hidetoshi Matsukawa^{1

3}, Mohammad-Mahdi Sowlat¹, Atakan Orscelik⁴, Noah L A Nawabi¹, Julio Isidor¹, Ilko Maier⁵, Pascal Jabbour⁶, Joon-Tae Kim⁷, Stacey Q Wolfe⁸, Ansaar Rai⁹, Robert M Starke¹⁰, Marios-Nikos Psychogios¹¹, Edgar A Samaniego¹², Shinichi Yoshimura³, Hugo Cuellar¹³, Brian M Howard^{14

15}, Ali Alawieh¹⁴, Ali Alaraj¹⁶, Mohamad Ezzeldin^{17

18}, Daniele G Romano¹⁹, Omar Tanweer²⁰, Justin R Mascitelli²¹, Isabel Fragata²², Adam J Polifka²³, Fazeel Siddiqui²⁴, Joshua W Osbun²⁵, Ramesh Grandhi²⁶, Roberto Javier Crosa²⁷, Charles Matouk²⁸, Min S Park²⁹, Waleed Brinjikji³⁰, Mark Moss³¹, Ergun Daglioglu³², Richard Williamson³³, Pedro Navia³⁴, Peter Kan³⁵, Reade Andrew De Leacy³⁶, Shakeel A Chowdhry³⁷, David Altschul³⁸, Alejandro M Spiotta³⁹, Michael R Levitt⁴⁰, Nitin Goyal²

Affiliations

¹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
² Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
³ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
⁴ Department of Neurosurgery, UCSF School of Medicine, San Francisco, California, USA.
⁵ Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany.
⁶ Department of Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁷ Department of Neurology, Chonnam National University Medical School, Gwangju, Gwangju, Korea (the Republic of).
⁸ Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
⁹ Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA.
¹⁰ Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹¹ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹² Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹³ Department of Neurosurgery, LSUHSC, Shreveport, Louisiana, USA.
¹⁴ Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁵ Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁶ Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
¹⁷ Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA.
¹⁸ Department of Neuroendovascular surgery, HCA Houston, Houston, Texas, USA.
¹⁹ Department of Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
²⁰ Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
²¹ Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²² Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²³ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²⁴ Department of Neuroscience, University of Michigan Health-West, Wyoming, Wyoming, USA.
²⁵ Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁶ Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁷ Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
²⁸ Department of Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁹ Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
³⁰ Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA.
³¹ Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, Arizona, USA.
³² Department of Neurosurgery, Ankara Bilkent City Hospital, Ankara, Turkey.
³³ Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
³⁴ Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁵ Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
³⁶ Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
³⁷ Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
³⁸ Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, USA.
³⁹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA [email protected].
⁴⁰ Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.

PMID: 39179373
DOI: 10.1136/jnis-2024-021975

Abstract

Background: A combination of intravenous (IVT) or intra-arterial (IAT) thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been investigated. However, there is limited data on patients who receive both IVT and IAT compared with IVT alone before MT.

Methods: STAR data from 2013 to 2023 was utilized. We performed propensity score matching between the two groups. The primary outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day modified Rankin Scale (mRS) score 0-2. Secondary outcomes included successful recanalization (modified treatment in cerebral infarction (mTICI) ≥2B, ≥2C), early neurological improvement, any intracranial hemorrhage (ICH), and 90-day mortality.

Results: A total of 2454 AIS-LVO patients were included. Propensity matching yielded 190 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio (OR): 0.80, 95% confidence interval (CI) 0.51-1.24, P=0.37; OR: 0.60, 95% CI 0.29 to 1.24, P=0.21, respectively). Rates of successful recanalization and early neurological improvement (ENI) were significantly lower in MT+IVT + IAT. mRS 0-1 and mortality were not significantly different between the two groups. However, the MT+IVT + IAT group demonstrated superior rates of good functional outcomes (90-day mRS 0-1) compared with patients in the MT+IVT group who had mTICI ≤2B, (OR: 2.18, 95% CI 1.05 to 3.99, P=0.04).

Conclusion: The combined use of IAT and IVT thrombolysis in AIS-LVO patients undergoing MT is safe. Although the MT+IVT+ IAT group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes were favorable in this group suggesting a potential delayed benefit of IAT.

Keywords: Stroke; Thrombectomy; Thrombolysis.