Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis.

INTRODUCTION: It is poorly understood if endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) better facilitates clinical outcomes in patients with acute basilar artery occlusion (BAO) ischemic stroke. METHODS: A systematic literature review and meta-analysis was completed to investigate the outcomes of EVT with IVT versus direct EVT alone in acute BAO. Data was collected from the literature and pooled with the authors' institutional experience. The primary outcome measure was 90-day modified Rankin sale (mRS) of 0-2. Secondary measures were successful post-thrombectomy recanalization defined as mTICI ≥2b, 90-day mortality, and rate of symptomatic ICH. RESULTS: Our institutional experience combined with three multicenter studies resulted in a total of 1,127 patients included in the meta-analysis. 756 patients underwent EVT alone, while 371 were treated with EVT+IVT. Patients receiving EVT+IVT had a higher odds of achieving a 90-day mRS of ≤ 2 compared to EVT alone (OR: 1.50, 95% CI 1.15 to 1.95, P =0.002, I2 =0%). EVT+IVT also had a lower odds of 90-day mortality (OR: 0.57, 95% CI 0.37 to 0.89, P=0.01, I2=24%). There was no difference in sICH between the two groups (OR: 1.0, 95% CI: 0.56 to 1.79, P=0.99, I2=0%). There was also no difference in post-thrombectomy recanalization rates defined as mTICI ≥2b (OR: 1.11, 95% CI 0.70 to 1.75, P = 0.65, I2=37%). CONCLUSIONS: On meta-analysis, EVT with bridging IVT results in superior 90-day functional outcomes and lower 90-day mortality without increase in symptomatic ICH. These findings likely deserve further validation in a randomized controlled setting.

Approaches to and outcomes of intra-arterial tPA in embolectomy for large vessel occlusion.

INTRODUCTION: Intra-arterial tissue plasminogen activator (IA tPA) is sometimes used in conjunction with aspiration catheters and stentrievers to achieve recanalization in endovascular thrombectomy (ET) for large vessel occlusion (LVO). Reports of safety and efficacy of this approach are limited by technical heterogeneity and sample size. METHODS: We retrospectively reviewed a data set of patients undergoing ET for LVO between August 2017 and September 2020 to identify those that received IA tPA. IA tPA usage, timing and dosage was at the discretion of the operative neurosurgeon. We identified three broad categories of IA tPA administration: (1) adjunctive with the first pass; (2) salvage with subsequent passes after first pass achieved incomplete revascularization; and (3) post-thrombectomy residual distal occlusions. Univariate and multivariate logistic regression were performed to test associations with recanalization, hemorrhage, and functional independence. RESULTS: Among 271 patients, 158 (58%) patients had IA tPA, of which 83 received adjuvant IA tPA, 60 received salvage IA tPA, and 15 received post-thrombectomy IA tPA for distal occlusions. There were no differences in demographics, stroke etiology and premorbid medications between these groups. Patients receiving salvage IA tPA had longer times from groin access to recanalization and more passes, as expected. On multivariate analysis neither adjunctive nor salvage IA tPA was significantly associated with recanalization, post-operative hemorrhage, or functional outcomes. On univariate analysis, patients receiving salvage IA tPA had lower rates of TICI 3 or 2b revascularization (80% vs. 89% adjunctive and 92% no IA tPA, p =  0.003) and higher rates of any postoperative hemorrhage (33% vs. 22% adjunctive and 19% no IA tPA, p =  0.003). CONCLUSIONS: In this retrospective, single-institution series, IA tPA used adjunctively or as salvage therapy in ET for LVO was not associated with recanalization, post-operative hemorrhage, or functional outcomes, suggesting IA tPA is an available modality that can be utilized in cases of recalcitrant clots.