Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction?

Abstract

BackgroundRecent data suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT.MethodsThe Endovascular Treatment in Ischemic Stroke registry is an ongoing, prospective, observational study in 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (eTICI3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into 2 groups according to IVT use before EVT and propensity score matching (PSM) was used to balance the 2 groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0‐2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, NIHSS, ASPECTS and time from symptom onset to puncture.ResultsAmong 5429 patients included in the ETIS registry, 1093 were included in the study including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, IVT+EVT group had a favorable shift in the overall mRS score distribution (aOR=1.41, 95%CI, 1.04‐1.91, p=0.023) and higher rates of favorable outcome (61.1% versus 48.7%; aOR=1.49, 95%CI, 1.02‐2.20, p=0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% versus 4.3%; aOR=1.16; [95% CI, 0.53–2.54]; p=0.709).ConclusionsIn clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk.This article is protected by copyright. All rights reserved.