Introduction/Purpose Up to 20% patients fail to achieve reperfusion after mechanical thrombectomy (MT). In cases of failed intracranial recanalization despite MT, bailout intracranial rescue stenting (RS) may be beneficial for successful recanalization. This is particularly applicable in patients who have underlying intracranial atherosclerotic disease associated with >70% residual stenosis or occlusion due to underlying dissection. Recent studies have suggested that RS is effective and safe, however this is still a topic of active investigation. Typically, patients who require RS will also necessitate immediate platelet inhibition to prevent thromboembolic complications. However, there is limited data supporting the safety of RS in patients treated with prior intravenous thrombolysis. Here, we aim to evaluate the safety of RS for ongoing emergent large vessel occlusion after failed MT in patients who have received prior treatment with intravenous recombinant tissue plasminogen activator (IV tPA).

Material and Methods This is a single center retrospective case series. We screened 5677 consecutive patients who presented with acute stroke symptoms to our stroke center between 2013 and 2022. 954 underwent endovascular treatment. 69 patients required rescue intracranial stenting due to failed recanalization with MT. From these patients, 23 patients received IV tPA prior to the endovascular procedure. We collected data regarding patient characteristics, initial NIHSS and ASPECT score, the degree of recanalization by Modified Thrombolysis in Cerebral Infarction (mTICI), modified Rankin Scale (mRS) at 3 months after stroke, asymptomatic and symptomatic intracranial hemorrhage (sICH) according to European Cooperative Acute Stroke Study II (ECASS) criteria and mortality rate within 90 days of treatment.

Results 69 patients were included in the analysis, 46 in the no IV tPA group and 23 in the IV tPA group. The average age was 64 vs 61. The average presenting NIHSS was 12 vs 19. The rate of successful recanalization TICI 2B-3 was 45/46 (98%) vs 21/23 (91%). The rate of all intracranial hemorrhage was 18/46 (39%) vs 11/23 (48%). The rate of symptomatic hemorrhage was 5/46 (11%) vs 3/23 (13%). The 90-day good mRS (0-2) score was 12/46 (26%) vs 10/23 (43%). The all-cause mortality rate at 90 days was 13.46 (28%) vs 9/23 (39%).

Conclusions In this retrospective study of a 10-year experience at a high-volume comprehensive stroke center, our study shows that rescue stenting after failed mechanical thrombectomy in the setting of prior administration of IV thrombolysis appears to be associated with a higher rate of all types of intracranial hemorrhages, but similar rates of symptomatic intracranial hemorrhage. 90-day functional status was better in the patients who received IV tPA, although the 90-day mortality was higher. Our report suggests that further larger studies are needed to determine the safety and efficacy of RS for failed mechanical thrombectomy in the setting of intravenous thrombolysis.

Disclosures S. Nedelcu: None. A. Kuhn: None. J. Singh: 2; C; Medtronic. N. Henninger: None. A. Puri: 2; C; Medtronic, Stryker, Cerenovus, Microvention, Agile, QApel, Arsenal, Imperative Care.