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The pendulum has swung again. Just within the last decade, the uncertain position of endovascular therapy (EVT) of emergent large vessel occlusion (ELVO) in acute ischemic stroke took a historic 180° turn. EVT in patients with ELVO is now supported by multiple randomized controlled trials and has been endorsed by various professional organizations throughout the world with a class I recommendation.1–10 Emerging data now raise questions about whether adjunctive intravenous recombinant tissue plasminogen activator (rtPA, alteplase) yields additional benefit beyond EVT alone.11 12 There is no additional benefit of thrombolysis in patients presenting with myocardial infarction and this approach has largely been abandoned in patients who have access to percutaneous coronary intervention within 120 min of symptoms onset.
Initial suggestion of alteplase ‘futility’ was advanced by the HERMES (Highly Effective Reperfusion Using Multiple Endovascular Devices) collaboration from a meta-analysis of individual patient data from five randomized trials (MR CLEAN, SWIFT PRIME, EXTEND-IA, ESCAPE, and REVASCAT).1–5 The treatment effect size of thrombectomy in patients who did not receive alteplase was similar to patients who were treated with both approaches. These findings are in keeping with previous retrospective analyses as well as post-hoc analyses of individual trials.13 Several ongoing trials are testing the role of systemic thrombolysis in patients treated with thrombectomy around the world, such as MR CLEAN NO …
Contributors MM and APJ contributed equally.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MM: Grants - NIH R21NS10957; Consultant - Medtronic, Canon Medical, Cerenovus; Stock options - Serenity medical, Synchron, Endostream, VICIS.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.