Article Commentary: “Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment”
Walter Valesky, MD
Flint AC, Avins AL, Eaton A, Uong S, Cullen SP, Hsu DP, Edwards NJ, Reddy PA, Klingman JG, Rao VA, et al. Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment. Stroke. 2020;51:2697-2704.
The authors utilize a unique approach to weigh-in on a brewing controversy in acute ischemic stroke management: Is intravenous thrombolysis (IVT) beneficial in large vessel occlusion (LVO) in patients receiving endovascular therapy (EVT)? Rather than reporting on symptomatic intracranial hemorrhage, as is typical in studies evaluating IVT, these authors evaluated distal migration of clot that was subsequently not amenable to retrieval with EVT in patients treated with and without thrombolytics. The hypothesis being that IVT will reduce clot size to a point that it may be dislodged from a larger, more proximal vessel to embolize into a smaller caliber, more distal vessel and not be amenable to EVT.
For their evaluation, the authors utilized a retrospective record review of patients evaluated at the Kaiser Permanente healthcare system in Northern California undergoing EVT after presenting with symptoms of acute ischemic stroke. EVT was performed at one of two comprehensive stroke centers (CSC) in the area functioning as a receiving hospital for 19 other primary stroke centers (PSC). Patients were included whether they initially presented to the PSC and were transferred or if they presented directly to the CSC. Successful recanalization was defined as a modified thrombolysis in cerebral infarction (mTICI) scale of 2b/3.