Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment

Abstract

Background and Purpose: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. Methods: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. Results: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P <0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST ( P <0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. Conclusions: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

“…Furthermore, a recent study covering 21 hospitals showed that DMVO occurred in one in four patients receiving intravenous tissue plasminogen activator in whom distal MT was not attempted in 41.3%, thereby depriving a significant number of patients of a possible better clinical outcome. 19 Intra-arterial thrombolysis may be achieved as an alternative to DMVO. 20 In the Bernese experience, the TICI rate was improved in 34% of patients treated by adjunctive intra-arterial Urokinase after incomplete or failed thrombectomy.…”

Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

“…The recently published RCT comparing endovascular thrombectomy with or without IVT in patients with LVO showed that MTE without prior IVT turned out to be non-inferior with regard to functional outcome, raising concerns that patients with LVO eligible for MTE are not adequately treated in a DS setting ( 3 ). There are even indications that IVT before MTE for LVO is associated with distal embolization, which in turn may reduce the chance that MTE can be attempted and recanalization can be achieved ( 16 ). But data on direct transfer of patients to CSC are still inconclusive as there are also trials which failed to prove non-inferiority of the MS model and proved its benefit prior ivtPA ( 17 ).…”

Monocyte Transmodulation: The Next Novel Therapeutic Approach in Overcoming Ischemic Stroke?

“…From the strategies of ischemic stroke treatment currently available, the best therapeutic approach in the acute phase is thrombolysis with tPA; however, the therapeutic time window is extremely narrow (<4.5 h within stroke onset) (164). To expand the therapeutic window and, consequently, reach more patients with ischemic stroke, recent studies have focused on investigating immune cell-targeted therapies, such as anti-inflammatory drugs that are fundamentally non-invasive and effective approaches for ischemic stroke prevention (165).…”