Abstract TP29: Benefit of Intravenous Alteplase Prior to Mechanical Thrombectomy of Large Vessel Occlusion Ischemic Stroke

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Purpose: Intravenous alteplase (IV-tPA) in combination with mechanical thrombectomy is the current standard treatment for ischemic stroke due to large vessel occlusion (LVO). IV-tPA has poor revascularization rate in LVO, and the benefit to the patient with LVO is unclear. The purpose of this study was to compare outcomes between patients with LVO who underwent thrombectomy alone and patients who received IV-tPA prior to thrombectomy.

Materials and Methods: We searched our institutional database for patients who presented with acute strokes between 1/2008 and 12/2014. We reviewed all clinical data and images of consecutive patients that underwent thrombectomy. Patients with ASPECT score less than 5 were excluded from the analysis. Group 1 received IV-tPA prior to thombectomy. Group 2 underwent thrombectomy alone.

Results: In Group 1, 67 patients (32 males) were identified with mean age of 65 years, mean ASPECT score of 7.1, mean initial NIHSS of 16, 58 (87%) with M1 occlusion and 9 (13%) with ICA occlusion. In Group 2, 46 patients (29 males) were identified with mean age of 66, mean ASPECT score of 7.4, mean initial NIHSS of 15, 40 (87%) with M1 occlusion and 6 (13%) with ICA occlusion. There were no significant differences in the baseline characteristics except that more males were represented in the Group 2. TICI 2b or greater revascularization was achieved at similar rates in both groups - 61% and 63% of patients in Group 1 and Group 2, respectively. Stentriever thrombectomy was performed in 43% vs 50% in Group 1 and Group 2, respectively. Mean 3-month follow up modified Rankin scale score was 3.4 in both groups.

Conclusions: Our analyses suggest that iv-tPA for LVO does not improve outcomes if the patient ultimately undergoes mechanical thrombectomy. IV-tPA may carry unnecessary cost in these patients with unclear benefit. Also, the majority of the patients in Group 2 presented with “wake-up strokes” or unknown time of onset and longer time to revascularization. Mechanical thrombectomy alone was the major factor in determining outcome regardless of iv-tPA administration.

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