Cost-effectiveness of intra-arterial thrombolysis after successful thrombectomy.

The impact of intra-arterial thrombolysis (IAT) following successful endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) remains uncertain. This study aims to assess the efficacy and safety of IAT as an adjunct to EVT in patients with AIS-LVO. We searched PubMed, Embase, and Cochrane databases to identify randomized controlled trials (RCTs) that compared EVT + IAT with EVT-only for AIS-LVO. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and mortality. The pooled data were analyzed using random-effects models. A total of four RCTs, involving 1395 patients, were included in the analysis. The results showed that patients who received EVT + IAT had a significantly higher likelihood of achieving an excellent functional outcome at 90 days compared to those who received EVT-only (risk ratio [RR], 1.16; 95% confidence interval [CI], 1.03-1.31). No statistically significant differences were observed between the EVT + IAT and EVT-only groups in terms of 90-day functional independence (RR, 1.03; 95% CI, 0.94-1.13), sICH (RR, 1.30; 95% CI, 0.80-2.13), or 90-day mortality (RR, 0.94; 95% CI, 0.76-1.17). Among patients with AIS-LVO who have undergone successful EVT, the use of adjunct IAT, compared to no additional treatment, was associated with a greater likelihood of achieving an excellent functional outcome at 90 days. CRD42024602099.

The Chemical Optimization of Cerebral Embolectomy (CHOICE) trial suggested that the administration of intra-arterial alteplase after successful endovascular thrombectomy (EVT) may improve neurological outcomes in patients with acute ischemic stroke due to large-vessel occlusion (AIS-LVO) in the anterior circulation. However, the use of adjunctive intra-arterial alteplase following successful EVT in acute posterior circulation stroke remains unexplored. This study aims to investigate the efficacy and safety of intra-arterial alteplase after successful EVT for AIS-LVO in the posterior circulation. To detect an estimated 15% difference in the primary outcome between the two groups, a total of 376 patients will be enrolled. This sample size allows for 80% power and a 5% significance level, with an interim analysis planned after half of the sample (188 patients) has completed a 90-day follow-up. The Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for Acute Ischemic Stroke in the Posterior Circulation (IAT-TOP) trial is a multicenter, prospective, randomized clinical trial using an open-label treatment design with blinded endpoint assessment (PROBE) conducted in China. Patients with acute basilar artery occlusion will be randomly assigned in a 1:1 ratio to receive either intra-arterial alteplase (0.225 mg/kg; maximum dose, 22.5 mg) or standard care following successful thrombectomy (defined as expanded thrombolysis in cerebral infarction [eTICI] ⩾ 2b50). The primary outcome is the modified Rankin Scale (mRS) score of 0-2 at 90 days. Key secondary outcomes include changes in eTICI scores after intra-arterial thrombolysis (in the experimental group), mRS 0-3 at 90 days, ordinal shift analysis of mRS at 90 days, early neurological improvement at 48 h, and improvement in National Institutes of Health Stroke Scale (NIHSS) scores at 48 h and 7 days or discharge. Safety outcomes include symptomatic intracranial hemorrhage (sICH) rates at 48 h, 90-day mortality, non-intracranial hemorrhagic complications, and non-hemorrhagic serious adverse events. The IAT-TOP trial will provide crucial evidence regarding the potential benefits of adjunctive intra-arterial alteplase in patients with AIS-LVO in the posterior circulation following successful thrombectomy. ClinicalTrials.gov NCT05897554.

Intra-arterial thrombolytics after successful recanalization in endovascular thrombectomy for large-vessel occlusion acute ischemic stroke: A comprehensive meta-analysis of randomized controlled trials.

Despite high recanalization rates with endovascular thrombectomy (EVT) for large vessel occlusions, functional outcomes remain suboptimal. This study investigates whether adjunctive intra-arterial (IA) thrombolysis following successful EVT can improve patient outcomes. A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We searched Medline, Embase, Web of Science, and Cochrane databases. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for functional and safety outcomes. Seven trials (2131 patients) were included. IA thrombolysis was administered to 1081 (50.7%) patients. Patients receiving adjunctive IA thrombolysis had higher odds of excellent functional outcomes (modified Rankin Scale (mRS) 0-1) at 90 days (OR 1.44, 95% CI 1.21 to 1.72) compared with the EVT-alone group while maintaining similar rates of symptomatic intracerebral hemorrhage (sICH; OR 1.15, 95% CI 0.75 to 1.75). Subgroup analysis of excellent functional outcomes showed that the benefits of IA thrombolysis were primarily observed in specific patient populations: those treated with alteplase 0.225 mg/kg or tenecteplase 0.125 mg/kg, patients with lower expanded Thrombolysis in Cerebral Infarction (eTICI) scores, higher initial National Institutes of Health Stroke Scale (NIHSS), and those with cardioembolic etiology. Mortality rates and good functional outcomes (mRS 0-2) remained comparable between treatment groups. Adjunctive IA thrombolysis following successful EVT may improve functional outcomes without added risk of sICH. Certain patient subgroups (those with lower recanalization rates, higher NIHSS, and cardioembolic etiology) and specific thrombolytic agents and dosages (alteplase 0.225 mg/kg, tenecteplase 0.125 mg/kg) appear to derive greater benefits from this approach. Further research is needed to validate these findings and refine patient selection.

Intravenous antihypertensives are frequently used to control blood pressure after successful endovascular thrombectomy (EVT), yet studies investigating the relationship between intravenous antihypertensive use and functional outcomes after successful EVT remain limited. We conducted an exploratory secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control), which compared intensive (systolic blood pressure <140 mm Hg) versus conventional blood pressure management (systolic blood pressure, 140-180 mm Hg) within the first 24 hours after successful recanalization across 19 stroke centers in South Korea between June 2020 and November 2022. Patients were classified according to the administration of intravenous antihypertensives within the initial 24 hours after enrollment. The primary efficacy outcome was functional independence (modified Rankin Scale score of 0-2) at 3 months. Of the 302 patients (median, 75 years; 180 [59.6%] men), 141 (46.7%) received intravenous antihypertensives within the first 24 hours after EVT. Among the 141 patients who received intravenous antihypertensives, 133 (94.3%) were treated with nicardipine, 10 (7.0%) received labetalol, and 2 (1.4%) were administered both drugs. Patients who received intravenous antihypertensives had significantly lower rates of functional independence at 3 months (adjusted odds ratio, 0.51 [95% CI, 0.27-0.95]; P=0.035) and excellent neurological recovery at 24 hours (adjusted odds ratio, 0.46 [95% CI, 0.22-0.94]; P=0.036), as well as higher stroke-related mortality rates (adjusted odds ratio, 4.21 [95% CI, 1.24-16.4]; P=0.027), compared with patients who did not receive intravenous antihypertensives. Symptomatic intracerebral hemorrhage was not significantly different between groups (adjusted odds ratio, 1.67 [95% CI, 0.68-4.19]; P=0.267). The use of intravenous antihypertensives within the first 24 hours after successful EVT was associated with worse functional outcomes at 3 months. This finding highlights the need for a cautious assessment of the risks and benefits of administering intravenous antihypertensives immediately after EVT. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04205305.

The associations between blood pressure (BP) decreases induced by medication and functional outcomes in patients with successful endovascular thrombectomy remain uncertain. To evaluate whether BP reductions induced by intravenous BP medications are associated with poor functional outcomes at 3 months. This cohort study was a post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control trial, a comparison of intensive and conventional BP management during the 24 hours after successful recanalization from June 18, 2020, to November 28, 2022. This study included 302 patients who underwent endovascular thrombectomy, achieved successful recanalization, and exhibited elevated BP within 2 hours of successful recanalization at 19 stroke centers in South Korea. A BP decrease was defined as at least 1 event of systolic BP less than 100 mm Hg. Patients were divided into medication-induced BP decrease (MIBD), spontaneous BP decrease (SpBD), and no BP decrease (NoBD) groups. The primary outcome was a modified Rankin scale score of 0 to 2 at 3 months, indicating functional independence. Primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and mortality due to index stroke within 3 months. Of the 302 patients (median [IQR] age, 75 [66-82] years; 180 [59.6%] men), 47 (15.6%)were in the MIBD group, 39 (12.9%) were in the SpBD group, and 216 (71.5%) were in the NoBD group. After adjustment for confounders, the MIBD group exhibited a significantly smaller proportion of patients with functional independence at 3 months compared with the NoBD group (adjusted odds ratio [AOR], 0.45; 95% CI, 0.20-0.98). There was no significant difference in functional independence between the SpBD and NoBD groups (AOR, 1.41; 95% CI, 0.58-3.49). Compared with the NoBD group, the MIBD group demonstrated higher odds of mortality within 3 months (AOR, 5.15; 95% CI, 1.42-19.4). The incidence of symptomatic intracerebral hemorrhage was not significantly different among the groups (MIBD vs NoBD: AOR, 1.89; 95% CI, 0.54-5.88; SpBD vs NoBD: AOR, 2.75; 95% CI, 0.76-9.46). In this cohort study of patients with successful endovascular thrombectomy after stroke, MIBD within 24 hours after successful recanalization was associated with poor outcomes at 3 months. These findings suggested lowering systolic BP to below 100 mm Hg using BP medication might be harmful.

The benefits and risks of adjunctive intra-arterial thrombolysis (IAT) after successful endovascular thrombectomy (EVT) in acute ischemic stroke due to large vessel occlusion (AIS-LVO) remain uncertain. This study aimed to evaluate the efficacy and safety of IAT in this setting. We systematically searched PubMed, Embase, Web of Science, CENTRAL, and ClinicalTrials.gov from inception to February 2025, and reviewed abstracts from the 2025 International Stroke Conference, to identify randomized controlled trials (RCTs) comparing IAT versus placebo or best medical management in AIS-LVO patients who achieved successful reperfusion after EVT. Outcome measures included 90-day excellent (modified Rankin Scale [mRS] 0-1) and good (mRS 0-2) functional outcomes, 90-day reduced disability (≥ 1-point mRS improvement), symptomatic intracranial hemorrhage (sICH), any ICH, and 90-day mortality. A random-effects model was employed for the meta-analysis. Seven RCTs with 2131 patients (1083 assigned to IAT, and 1048 to control) were included. Compared to controls, IAT was associated with significantly higher likelihood of 90-day excellent functional outcomes (risk ratio 1.23, 95% confidence interval [CI] 1.11-1.36; I2 = 0%) and reduced disability (common odds ratio 1.20, 95% CI 1.03-1.40; I2 = 0%), but not with 90-day good functional outcomes. Risks of any ICH, sICH, and mortality were similar between groups. Subgroup analyses suggested numerically higher odds of excellent functional outcomes among patients with anterior circulation LVO or those receiving IA alteplase/tenecteplase. Adjunctive IAT following successful EVT in AIS-LVO patients led to improved 90-day excellent functional outcomes and reduced disability without increasing sICH or mortality risks.

BackgroundThe trajectory of ischemic stroke patients attributable to large vessel occlusion is fundamentally altered by endovascular thrombectomy. This study aimed to develop a nomogram for predicting 3‐month mortality risk in patients with ischemic stroke attributed to artery occlusion in anterior circulation who received successful endovascular thrombectomy treatment.Methods and ResultsPatients with successful endovascular thrombectomy (modified Thrombolysis in Cerebral Infarction IIb or III) were enrolled from a multicenter registry as the training cohort. Step‐wise logistic regression with Akaike information criterion was utilized to establish the best‐fit nomogram. The discriminative value of the nomogram was tested by concordance index. An additional 224 patients from 2 comprehensive stroke centers were prospectively recruited as the test cohort for validating the new nomogram. Altogether, 417 patients were enrolled in the training cohort. Age (odds ratio [OR], 1.07; 95% CI, 1.03−1.10), poor pretreatment collateral status (OR, 2.13; 95% CI, 1.18−3.85), baseline blood glucose level (OR, 1.12; 95% CI, 1.04−1.21), symptomatic intracranial hemorrhage (OR, 9.51; 95% CI, 4.54−19.92), and baseline National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.03−1.12) were associated with mortality and were incorporated in the nomogram. The c‐index of the nomogram was 0.835 (95% CI, 0.785–0.885) in the training cohort and 0.758 (95% CI, 0.667–0.849) in the test cohort.ConclusionsThe nomogram, composed of age, pretreatment collateral status, baseline blood glucose level, symptomatic intracranial hemorrhage, and baseline National Institutes of Health Stroke Scale score, may predict risk of mortality in patients with ischemic stroke and treated successfully with endovascular thrombectomy.

Endovascular thrombectomy (EVT) is a highly effective method of restoring blood flow in patients with large cerebral artery occlusion. However, it is not uncommon for neurological deficits to persist or even worsen despite successful recanalization.Objective: to identify factors associated with good and satisfactory functional recovery (mRS 0–3) following successful EVT (defined as achieving TICI 2b/3 reperfusion).Material and methods. This retrospective analysis included 90 patients with ischemic stroke in the carotid territory who underwent EVT with achieved TICI 2b/3 reperfusion. The prognostic value of clinical, neuroradiological, and periprocedural factors was assessed.Results. Univariate logistic regression analysis identified several predictors of good or satisfactory outcome after EVT: the degree of neurological disturbances (National Institutes of Health Stroke Scale, NIHSS score) on admission (OR 0.87; 95% CI 0.79–1.02; p=0.005), NIHSS at 24 hours post-EVT (OR 0.70; 95% CI 0.60–0.81; p&lt;0.0005), presence of T-occlusion of the internal carotid artery (OR 0.25; 95% CI 0.06–0.97; p=0.045), hemorrhagic transformation (OR 0.10; 95% CI 0.03–0.34; p&lt;0.0005), the early CT ischemic signs volume (OR 0.97; 95% CI 0.94–0.99; p&lt;0.001), volume with rCBF &lt;30% (OR 0.91; 95% CI 0.87–0.96; p&lt;0.0005), infarct core volume by day 3 (OR 0.95; 95% CI 0.92–0.97; p&lt;0.0005), systemic thrombolysis (OR 5.79; 95% CI 1.24–26.96; p&lt;0.0005), ASPECTS score (OR 2.43; 95% CI 1.67–3.53; p&lt;0.0005), eASPECTS score (OR 1.53; 95% CI 1.18–2.0; p=0.002), Tmax/rCBF mismatch (OR 1.09; 95% CI 1.03–1.16; p=0.002). In multivariate logistic regression, three independent predictors of good or satisfactory functional outcome were identified: ASPECTS score, number of thrombectomy passes, and hemorrhagic transformation (model sensitivity – 95.7%, specificity – 70.0%).Conclusion: The clinical outcome of ischemic stroke following successful recanalization is determined by a combination of factors reflecting both the initial state of brain tissue and the complexity of the procedure, as well as the occurrence of reperfusion-related postoperative complications.

ObjectiveTo demonstrate, by a cost-effectiveness analysis, the efficiency of mechanical thrombectomy (MT) versus medical management (MM) in patients with a low Alberta Stroke Program Early CT Score (ASPECTS) from the...

Background and Purpose The optimal blood pressure (BP) control after successful endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) with large vessel occlusion (LVO) remains debatable. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that evaluate the efficacy and safety of standard BP control (with systolic BP ≤180 mm Hg) versus intensive BP control (systolic BP <140 mm Hg) during the 24 hours after successful EVT in AIS with LVO.Methods PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Embase were searched to identify relevant trials. The crude odds ratio (OR) and 95% confidence interval (CI) were calculated and estimates using random-effects models were pooled. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO ID: CRD42023450673).Results Four RCTs involving 1,559 participants were included. Regarding efficacy outcomes, intensive BP control was associated with a lower likelihood of functional independence (OR: 0.68; 95% CI: 0.51–0.91 for modified Rankin Scale [mRS] ≤2) and walking without assistance (OR: 0.65; 95% CI: 0.53–0.81 for mRS ≤3). For safety outcomes, consistent with the efficacy findings, intensive BP control was significantly associated with severe disability or death (mRS 5 or 6) (OR: 1.34; 95% CI: 1.07–1.69). However, there were no significant differences including all-cause mortality, any intracerebral hemorrhage (ICH), symptomatic ICH, parenchymal hematoma type 2, and stroke recurrence.ConclusionWhile all four RCTs were conducted to demonstrate the superiority of intensive BP control over standard BP control, standard BP control may be beneficial for the outcome after EVT for AIS with LVO without increasing adverse safety outcomes. Caution should be needed with the application of intensive BP control during the 24 hours following successful recanalization after EVT.

For acute ischemic stroke (AIS) patients, successful endovascular thrombectomy (EVT) may not recover functional independence. One potential mechanism driving this disparity is no-reflow, a lack of perfusion despite recanalization of the large vessel occlusion (LVO). None of the published methods for assessing no-reflow have gained acceptance, and debate persists about isolating no-reflow from upstream hemodynamic anomalies as well as the temporal dynamics no-reflow assessment. This work conducts an exploratory analysis of the effect of time since EVT on the performance of different methods for assessing no-reflow. We identified a cohort of UCLA Health patients with successful LVO recanalization (≥ mTICI 2b) of a thrombus located in M1 or ICA. Patients were stratified into 'early' and 'follow-up' cohorts of < 24 and < 48 hours since EVT. A set of published methods using perfusion imaging for no-reflow detection were adapted to run semi-automatically for both cohorts. We compiled 83 imaging studies from 64 patients. No-reflow rates varied from 4 . 2 % to 51 . 4 % by method, time since EVT, and mTICI. Follow-up no-reflow rates more closely match the original literature across all methods. mTICI 2b patients likely inflated no-reflow, as rates dropped approximately 50 % for mTICI 2c/3 cases. Early cohort inter-method agreement shows kappa scores as low as - 0 . 017 , but improved up to 0 . 72 in the follow-up cohort. No-reflow exhibits substantial dependence on time across all no-reflow detection methods studied. Inter-method agreement is good for methods using the same perfusion parameters, but each method is subject to confounding influences, motivating an aggregate method for robust evaluation. The temporal dynamics of no-reflow detection raises questions about imaging timing post-EVT for detection within the intervention window.

Background Retinal artery occlusion can lead to sudden visual loss without pain. The acute management of retinal artery occlusion remains unresolved. Case Report A 65-year-old male was hospitalized to an emergency room for visual loss on the left side within 6 hours of onset. Combined occlusion at retinal artery and ciliary artery was confirmed by an ophthalmologist and we assessed ophthalmic artery occlusion. However, MRA revealed no significant steno-occlusion of internal carotid artery. Transfemoral cerebral angiography was carried out immediately and showed a movable thrombus at the orifice of the ophthalmic artery. We decided on endovascular thrombectomy to prevent permanent visual loss. Finally, his visual acuity was improved after successful thrombectomy. Conclusions Although MRA is intact, small thrombus right at the orifice of the ophthalmic artery can cause a sudden monocular visual loss due to occlusion of the retinal artery. In this setting, urgent endovascular thrombectomy can offer visual improvement. Key Words: Monocular blindness; Ophthalmic artery; Thrombectomy

This study evaluates the distribution and prognostic role of transcranial color-coded Doppler (TCCD) spectral patterns following a successful endovascular thrombectomy (EVT). This multicenter prospective study included patients with internal carotid or middle cerebral artery (MCA) occlusion treated in the early time window (< 6 h) with a successful EVT (mTICI ≥ 2b), without symptomatic hemorrhagic transformation within 24 h. TCCDs were performed 24-48 h and 7 days from EVT. TCCD flow was graded by Consensus on Grading Intracranial Flow Obstruction (COGIF) score (1: no flow; 2-3: low flow; 4a: normal; 4b: residual stenosis; 4c: hyperperfusion). MCA flow velocities were compared between sides and time points. Outcomes were clinical improvement (decrease of 8 points/30% on day 7 NIHSS vs. baseline) and three-month mRS. 188 ischemic stroke patients were included (48% female, median age 77). The median NIHSS was 16 at admission and 3 at day 7. Day 1 TCCD showed slightly higher velocities in the treated MCA compared to the contralateral MCA, without significant differences between day 1 and day 7. Despite mTICI ≥ 2b, 13/187 (7%) patients showed a partial recanalization or residual stenosis at 24 h. Clinical improvement was lacking in 27 patients (14.4%). COGIF scores 3 and 4b at day 1 were significantly associated with lack of improvement at day 7 (aOR 0.03, 95% CI 0.01-0.16, p < 0.001) and worse mRS score at 3 months (mRS ordinal shift analysis, aOR 7.78, 95% CI 2.16-28.54, p = 0.002). Day 1 post-EVT TCCD COGIF score, but no flow velocities alone, are associated with clinical outcomes.

Following an acute ischemic stroke, the risk of recurrent stroke is highest in the first 90 days. It is unclear whether this risk is altered by reperfusion therapy. In this meta-analysis, we aim to evaluate the risk of early recurrent stroke and other nonstroke thrombotic events postreperfusion therapy in acute ischemic stroke. In this meta-analysis, randomized controlled trials (RCTs) were included in adults aged 18 years or older with acute ischemic stroke, comparing reperfusion treatment with best medical management (MED). We searched PUBMED, Embase, Cochrane Library, and Web of Science databases. The studies were grouped into endovascular thrombectomy (EVT) versus MED and intravenous thrombolysis versus MED. We performed a meta-analysis using a random-effects model (restricted maximum likelihood) to estimate the log risk ratio (RR) of early recurrent stroke and nonstroke thrombotic events (NSTE)-including myocardial infarction, acute coronary syndrome, deep vein thrombosis, pulmonary embolism, and peripheral embolism-after reperfusion therapy compared with MED at 90 days after symptom onset. This study is registered with PROSPERO (The International Prospective Register of Systematic Reviews). A total of 15 RCTs (n=4898) comparing EVT versus MED observed no difference in early recurrent stroke (5.5%, 143/2618 versus 4.5%, 102/2280; RR, 1.2 [95% CI, 0.9-1.6]). Nine RCTs (n=7193) comparing intravenous thrombolysis versus MED observed no difference in early recurrent stroke (2%, 73/3615 versus 1.8%, 66/3578; RR, 1.1 [95% CI, 0.8-1.5]). Fourteen RCTs (n=4033) comparing EVT versus MED reported NSTE. There was no difference in NSTE in the EVT arm (3.1%, 62/2024 versus 3.1%, 62/2009; RR, 1 [95% CI, 0.7-1.4]). Five RCTs (n=4961) comparing intravenous thrombolysis versus MED observed no difference in NSTE (2%, 51/2479 versus 2.2%, 54/2482; RR, 0.9 [95% CI, 0.6-1.4]). Reperfusion therapies (EVT±intravenous thrombolysis) in acute ischemic stroke within 24 hours of symptom onset were not associated with increased recurrent stroke or NSTE within 90 days compared with best medical therapy. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42024542020.