• Lining Chen, Yina Wu, Jinbiao Yao, Qiaowei Wu, Guang Zhang, Shancai Xu, Pengfei Yang, Yongwei Zhang, Lei Zhang, Zifu Li, Pengfei Xing, Hongjian Shen, Huaizhang Shi, Jianmin Liu, Chenghua Xu, Pei Wu, and DIRECT-MT Investigators.
• Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China.
• World Neurosurg. 2025 Jan 6; 194: 123569123569.

BackgroundThere are still some patients with acute anterior circulation large vessel occlusion stroke experienced unsuccessful recanalization after endovascular thrombectomy (EVT). The efficacy of intravenous alteplase before thrombectomy for such patients is unknown. We performed this study to investigate whether prior intravenous alteplase could affect the outcome of patients with unsuccessful recanalization.MethodsThis is a post-hoc analysis of the DIRECT-MT trial (direct intraarterial thrombectomy in order to revascularize acute ischemic stroke patients with large vessel occlusion efficiently in Chinese Tertiary Hospitals: a multicenter randomized clinical trial). Patients with final extended thrombolysis in cerebral infarction score of 0-2a were included. Patients with successful recanalization (modified treatment in cerebral ischemia 2b-3) or could not be assessed for modified treatment in cerebral ischemia were excluded. The primary outcome was the 90-day modified Rankin Scale (mRS) score, while secondary outcomes included 90-day functional independence (mRS 0-2), recanalization (modified arterial occlusive lesion) rates at 24-72 hours by computed tomography angiography, infarction volume on computed tomography, and rates of symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage.ResultsAmong 656 randomized patients, 92 patients with unsuccessful recanalization were included, of which 55 patients underwent EVT alone (EVT group) and 37 patients underwent EVT preceded by intravenous alteplase (combination group). No statistically significant difference in the 90-day mRS score was observed between the 2 groups (adjusted common odds ratio = 1.65; 95% confidence interval, 0.76 to 3.59). The volume of infarction, the proportion of 90-day functional independence, recanalization rates at 24-72 hours, rates of symptomatic intracranial hemorrhage, and rates of asymptomatic intracranial hemorrhage were similar in both groups.ConclusionsWe found no evidence that prior intravenous alteplase could affect the clinical or imaging outcome in patients with acute anterior circulation large vessel occlusion stroke and unsuccessful recanalization after EVT.Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.

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