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IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion?
  1. Ameer E Hassan1,2,3,
  2. Victor M Ringheanu2,
  3. Laurie Preston2,3,
  4. Wondwossen Tekle1,3,
  5. Adnan I Qureshi4,5
  1. 1 Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
  2. 2 Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
  3. 3 Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
  4. 4 Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
  5. 5 Department of Neurology, University of Missouri School of Medicine, Columbia, Missouri, USA
  1. Correspondence to Dr Ameer E Hassan, Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, TX 78539, USA; ameerehassan{at}


Background Endovascular treatment (EVT) is a widely proved method to treat patients diagnosed with intracranial large vessel occlusions (LVOs); however, there has been controversy about the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT.

Objective To compare the outcomes of all patients with LVO treated with IV tPA +EVT versus EVT alone within 4.5 hours of stroke onset.

Methods A prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2019 was used to examine variables such as demographics, comorbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (ICH), mortality rate, and good/poor outcomes as shown by the modified Thrombolysis in Cerebral Infarction score and modified Rankin Scale (mRS) assessment at discharge. The outcomes between patients receiving IV tPA+EVT on admission and patients who underwent EVT alone were compared.

Results Of 588 patients with acute ischemic stroke treated with EVT, a total of 189 met the criteria for the study (average age 70.44±12.90 years, 42.9% women). Analysis of 109 patients from the group receiving EVT+IV tPA (average age 68.17±14.28 years, 41.3% women), and 80 patients from the EVT alone group was performed (average age 73.54±9.84 years, 45.0% women). Four patients (5.0%) in the EVT alone group experienced symptomatic ICH versus 15 patients (13.8%) in the IV tPA+EVT group (p=0.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; p=0.0056).

Conclusion IV tPA in addition to EVT was associated with an increase in the rate of ICH in patients with LVO treated within 4.5 hours and in patients’ length of stay. Further research is required to determine whether EVT treatment alone in patients with LVO treated within 4.5 hours is a more effective option.

  • hemorrhage
  • intervention
  • stroke
  • thrombectomy
  • thrombolysis

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  • Contributors AEH provided the research question, analyzed the data, and revised the paper. VMR developed the statistical analyses, drafted the paper, and revised the paper. LP, WT, and AQ revised the paper.

  • 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 AEH: consultant for Medtronic, Microvention, Penumbra, Stryker, Genentech, Balt,, and GE Healthcare.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. This includes individual participation data that underlie the results reported in this article, after deidentification. Data may be shared with investigators whose proposed use of the data has been approved by an independent review committee identified for this purpose and may be used for individual participant data meta-analysis. Contact corresponding author.