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Original research
Intravenous alteplase has different effects on the efficacy of aspiration and stent retriever thrombectomy: analysis of the COMPASS trial
  1. Maxim Mokin1,
  2. Muhammad Waqas2,
  3. Johanna T Fifi3,
  4. Reade De Leacy3,
  5. David Fiorella4,
  6. Elad I Levy2,
  7. Kenneth Snyder2,
  8. Ricardo A Hanel5,
  9. Keith Woodward6,
  10. Imran Chaudry7,
  11. Ansaar T Rai8,
  12. Donald Frei9,
  13. Josser E Delgado Almandoz10,
  14. Michael Kelly11,
  15. Adam S Arthur12,
  16. Blaise W Baxter13,
  17. Joey English14,
  18. Italo Linfante15,
  19. Kyle M Fargen16,
  20. Aquilla Turk7,
  21. J Mocco3,
  22. Adnan H Siddiqui2
  1. 1 Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, USA
  2. 2 Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  3. 3 Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  4. 4 Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
  5. 5 Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
  6. 6 Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA
  7. 7 Neurosurgery, Prisma Health Upstate, Greenville, South Carolina, USA
  8. 8 Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
  9. 9 Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
  10. 10 Neurointerventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
  11. 11 Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  12. 12 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  13. 13 Lehigh Valley Health Network, Allentown, Pennysylvania, USA
  14. 14 Neurology and Radiology, University of California San Francisco (UCSF), San Francisco, California, USA
  15. 15 Baptist Cardiac and Vascular Institute, Miami, Florida, USA
  16. 16 Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
  1. Correspondence to Dr Maxim Mokin, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL 33606, USA; mokin{at}


Background There is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).

Methods This was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration.

Results In the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0–2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0).

Conclusions Prior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.

  • brain
  • stent
  • stroke
  • thrombectomy
  • thrombolysis

Data availability statement

Data are available upon reasonable request.Requests for data availability should be addressed to COMPASS principal investigators. Requests for data availability should be addressed to COMPASS principal investigators.

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Data availability statement

Data are available upon reasonable request.Requests for data availability should be addressed to COMPASS principal investigators. Requests for data availability should be addressed to COMPASS principal investigators.

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  • Contributors MM, MW, JM, AHS, AT: study concept and design. MM, MW: manuscript writing. MW, MM: statistical analysis. All authors edited the manuscript and approved the final version. AHS as guarantor accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • 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: Grant NIH R21NS109575. Consultant: Medtronic, Cerenovus. Stock options: Brain Q, Endostream Serenity Medical, Synchron. Assistant Editor for JNIS. MW: None. JTF: Consultant: Stryker, Penumbra, Microvention. Stocks: Cerebrotech, The Stroke Project. RDL: Consultant: Cerenovus, Stryker, Penumbra, Imperative Care, Siemens. Stock options: Synchron, Endostream, Q’Apel. Social Media Editor for JNIS. DF: Consultant: Balt USA, Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Marbelhead, Medtronic, MENTICE, Neuorogami, RAPID AI, Rapid Medical, Phenox. Associate Editor for JNIS. EIL: Consultant: Penumbra, NextGen Biologics, Rapid Medical, Cognition Medical, Three Rivers Medical, Stryker, MedX, Endostream Medical. KS: Consultant: Penumbra, Canon Medical Systems, Medtronic, Jacobs Institute, Neurovascular Diagnostics. RAH: Consultant: Penumbra, Endostream, Cerebrotech, Synchron, InNeuroCo, Medtronic, Microvention, Stryker, Cerenovus; Elum, Three Rivers. KW: Consultant: Penumbra. IC: Consultant: Medtronic, Microvention, Penumbra. Stocks: Cerenovus, Serenity Medical, Cerebrotech, Three Rivers Medical, Q’apel. ATR: Consultant: Penumbra, Microvention, Stryker. DF: Consultant: Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Siemens. JEDA: Consultant: Penumbra, Medtronic. MK: Consultant: Penumbra, Medtronic, Endostream. ASA: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker. Stocks: Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad, Vascular Simulations. BWB: Consultant: Penumbra, Medtronic, Stryker, Cerenovus,, 880 Medical, Route 92, Artio Medical. JE: Consultant: Penumbra, Medtronic, Stryker, Route 92 Medical. IL: Consultant: Penumbra, Medtronic, Stryker, Microvention, InNeuroCo, Three Rivers. KMF: Associate Editor for JNIS. AT: Consultant: Cardinal Consulting, Cerenovus, Corindus, Medtronic, Siemens, 880 Medical. Stock: Cerebrotech, Endostream. Imperative Care, Three Rivers Medical, Vastrax, Shape Memory, Synchron, Serenity Medical, Blink TBI, Echovate, RIST, Apama, Q’Apel, VizAi, Early Bird Medical, Rapid Medical, Spinnaker Medical. AHS: Stocks: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc., Buffalo Technology Partners, Inc., Cardinal Consultants, LLC, Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, Endostream Medical, Ltd, Imperative Care, Inc., Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., NeuroRadial Technologies, Inc., Neurotechnology Investors, Neurovascular Diagnostics, Inc., PerFlow Medical, Ltd, Q’Apel Medical, Inc.,, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Consultant/Advisory Board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Penumbra, Q’Apel Medical, Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol,, Inc., W.L. Gore & Associates. JM: Stock options: Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Serenity, Cardinal Consulting, NTI, RIST,, Synchron. Consultant: Imperative Care, Cerebrotech, VIseon, Endostream, Vastrax, RIST, Synchron,, Perflow, CVAid. Associate Editor for JNIS.

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

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