Elawady SS, Abo Kasem R, Mulpur B, Cunningham C, Matsukawa H, Sowlat MM, Orscelik A, Nawabi NLA, Isidor J, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Alaraj A, Ezzeldin M, Romano DG, Tanweer O, Mascitelli JR, Fragata I, Polifka AJ, Siddiqui F, Osbun JW, Grandhi R, Crosa RJ, Matouk C, Park MS, Brinjikji W, Moss M, Daglioglu E, Williamson R, Navia P, Kan P, De Leacy RA, Chowdhry SA, Altschul D, Spiotta AM, Levitt MR, and Goyal N
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., Competing Interests: Competing interests: HM received a lecture fee from Daiichi-Sankyo and Stryker and consulting services fees from B Braun. ILM: speakers' honoraria from Pfizer and Bristol-Myers Squibb. RMS: research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. MNP: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30198783) and TECNO trial (32003B204977), Grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted Grants for the DISTAL trial from Stryker Neurovascular Inc., Phenox GmbH, Penumbra Inc., and Rapid Medical Inc., Sponsor-PI SPINNERS trial (Funded by a Siemens Healthineers AG Grant), Research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF, and ESCAPE-NEXT trials. Speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. ES: consults for Medtronic, Microvention, Rapid Medical. SY: received lecture fees from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. HC: Consultant for Medtronic and Microvention. JAG: Georgia Research Alliance, Emory Medical Care Foundation, Neurosurgery Catalyst, Consultant: Cognition, Imperative Care. DGR: Consultant for Penumbra, Balt, Microvention, Phenox. OT: Consulting Agreements: Viz.AI, Inc., Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention Inc, Medtronic Inc. Educational/Research Grants: Q’apel Inc, Steinberg Foundation. CM: Consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical. Speaker for Penumbra and Silk Road Medical. Contact PI for NIH Grant R21NS128641. MSP: Consultant for Medtronic. MRL: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers and Metis Innovative; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. WB: Holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. RW: Consultant for Medtronic, Stryker, and Synaptive Medical. PN: Consultant for Penumbra, Medtronic, Stryker, Cerenovus, and Balt. PK: Grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens. Consultant for Imperative Care and Stryker Neurovascular. Stock ownership in Vena Medical. RDL: PI for Imperative Trial; Research grants from Siemens Healthineers and Kaneka medical. Consultant for Cerenovus, Stryker Neurovascular and Sim & Cure. Minor equity interest Vastrax, Borvo medical, Synchron, Endostream, Von Vascular, Radical catheters, and Precision Recovery Inc. SAC: Consultant and proctor for Medtronic and Microvention. ME: Consultant for Viz.ai and Imperative care. Investments in Galaxy Therapeutics. DJA: Consultant for MicroVention, Stryker, and Cerenovus. RG: Consultant for Balt Neurovascular, Cerenovus, Medtronic Neurovascular, Rapid Medical, and Stryker Neurovascular. AMS: Consultant for Penumbra, Terumo, RapidAI, Cerenovus. AA: Consultant for Cerenovus. SSE, RAK, BM, CMC, MMS, AO, NLN, JI, PJ, JTK, SQW, AR, AA, JM, IF, AP, FS, JO, RC, MM, ED, NG: none., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)