Background Despite constant improvements in recent years, sufficient reperfusion after mechanical thrombectomy (MT) is not reached in up to 15% of patients with large vessel occlusion stroke (LVOS). The outcome of patients with unsuccessful reperfusion after MT especially after intravenous thrombolysis (IVT) use is not known. We investigated the influence of initial IVT in this particular group of patients with failed intracranial recanalization.
Methods We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry from January 2015 to December 2019. Patients presenting with LVOS of the anterior circulation and final modified Thrombolysis in Cerebral Infarction score (mTICI) of 0, 1 or 2a were included. Posterior circulation, isolated cervical carotid occlusions and successful reperfusions (mTICI 2b, 2c or 3) were excluded. The primary endpoint was favorable outcome (modified Rankin Scale score of 0–2) after 3 months. Secondary endpoints were safety outcomes including mortality, any intracranial hemorrhage (ICH), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) rates.
Results Among 5076 patients with LVOS treated with MT, 524 patients with insufficient recanalization met inclusion criteria, of which 242 received IVT and 282 did not. Functional outcome was improved in the MT+IVT group compared with the MT alone group, although the difference did not reach statistical significance (23.0% vs 12.9%; adjusted OR=1.82; 95% CI 0.98 to 3.38; p=0.058). However, 3 month mRS shift analysis showed a significant benefit of IVT (adjusted OR=1.68; 95% CI 1.56 to 6.54). ICH and sICH rates were similar in both groups, although PH rate was higher in the MT+IVT group (adjusted OR=3.20; 95% CI 1.56 to 6.54).
Conclusions Among patients with LVOS in the anterior circulation and unsuccessful MT, IVT was associated with improved functional outcome even after unsuccessful MT. Despite recent trials questioning the place of IVT in the LVOS reperfusion strategy, these findings emphasize a subgroup of patients still benefiting from IVT.
Data availability statement
The data used in this study are available from the corresponding author upon reasonable request.
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Collaborators On behalf of the Endovascular Treatment in Ischemic Stroke ETIS- Research Investigators: FOR : Michel Piotin, Raphael Blanc, Hocine Redjem, Simon Escalard, Jean-Philippe Desilles, Delvoye François, Stanislas Smajda, Benjamin Maier, Hebert Solène, Mikael Mazighi, Mikael Obadia, Candice Sabben, Seners Pierre, Raynouard Igor, Ovide Corabianu, Thomas de Broucker, Eric Manchon, Guillaume Taylor, Malek Ben Maacha, Thion Laurie-Anne, Lecler Augustin, Savatovsjy Julien. FOCH: Adrien Wang, Serge Evrard, Maya Tchikviladze, Nadia Ajili, Bertrand Lapergue, David Weisenburger-Lile, Lucas Gorza, Géraldine Buard, Oguzhan Coskun, Arturo Consoli, Federico Di Maria, Georges Rodesh, Sergio Zimatore, Morgan Leguen, Julie Gratieux, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll, Sylvie Marinier. LYON : Norbert Nighoghossian, Roberto Riva, Omer Eker, Francis Turjman, Laurent Derex, Tae-Hee Cho, Laura Mechtouff, Anne Claire Lukaszewicz, Frédéric Philippeau, Serkan Cakmak, Karine Blanc-Lasserre, Anne-Evelyne Vallet. BORDEAUX: Gaultier Marnat, Florent Gariel, Xavier Barreau, Jérôme Berge, Patrice Menegon, Igor Sibon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles, François Rouanet, Thomas Tourdias, Jean-Sebastien Liegey, Pierre Briau, Nicolas Pangon. NANTES : Romain Bourcier, Lili Detraz, Benjamin Daumas-Duport, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Hubert Desal, Benoît Guillon, Solène de Gaalon, Cécile Preterre. NANCY : Benjamin Gory, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, François Zhu, Emmanuelle Schmitt, Sophie Planel, Sébastien Richard, Lisa Humbertjean, Gioia Mione, Jean-Christophe Lacour, Nolwenn Riou-Comte, Gérard Audibert, Marcela Voicu, Ionel Alb, Marie Reitter, Madalina Brezeanu, Agnès Masson, Adriana Tabarna, Iona Podar, Sarah Guy, Fatiha Bechiri. LIMOGES: Francisco Macian-montoro, Suzanna Saleme, Charbel Mounayer, Aymeric Rouchaud. MONTPELLIER : Vincent Costalat, Caroline Arquizan, Cyril Dargazanli, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand, Lucas Corti, Federico Cagnazzo, Adrien ter Schiphorst. RENNES : Eugene Francois, Stéphane Vannier, Jean-christophe Ferre, helene Raoult, Thomas Ronziere, Maria Lassale, Christophe Paya, Jean-Yves Gauvrit, Clément Tracol, Sophie Langnier-Lemercier. PITIE-SALPETRIERE : Yves Samson, Charlotte Rosso, Anne Leger, Sandrine Deltour, Frederic Clarencon, Eimad Shotar. Kremlin-Bicêtre : Laurent Spelle, Christian Denier, Olivier Chassin, Vanessa Chalumeau, Jildaz Caroff, Olivier Chassin, Laura Venditti. Sainte ANNE : Olivier Naggara, Wagih Ben Hassen, Grégoire Boulouis, Christine Rodriguez-Régent, Denis Trystram, Basile Kerleroux, Guillaume Turc, Valérie Domigo, Catherine Lamy, Julia Birchenall, Clothilde Isabel, François Lun, Wassim Farhat, Matthieu Zuber, Olivier Heinzlef. TOULOUSE : Alain Viguier, Christophe Cognard, Anne Christine Januel, jean-Marc Olivot, Nicolas Raposo, Fabrice Bonneville, Jean François Albucher, Lionel Calviere, Jean Darcourt, Philippe Tall, Guillaume Bellanger, Louis Fontaine. CAEN : Emmanuel Touze, Charlotte Barbier, Romain Schneckenburger, Marion Boulanger, Julien Cogez, Sophie Guettier. BREST : Serge Timsit, Jean-christophe Gentric, Julien Ognard, Francois Mathias Merrien. ROUEN : Ozlem Ozkul Wermester, Evelyne Massardier, Chrysanthi Papagiannaki. BAYONNE: Frédéric Bourdain, Bernady Patricia, Lagoarde-Segot Laurent, Cailliez Hélène, Veunac Louis, Higue David. STRASBOURG: Wolff Valérie, Dr Pop Raoul, Beaujeux Rémi, Mihoc Dan-Sorin, Manisor Monica. VANNES: Le Bras Anthony, Evain Sarah, Le Guen Arnaud. PAU : Richter Sebastian, Hubrecht Regis, Demasles Stéphanie, Barroso Bruno. PERPIGNAN : Denis Sablot, Geoffroy Farouil, Maxime Tardieu, Philippe Smadja, Sabine Aptel, Ian.
Contributors CR, GM, BM, BG, RB, BL, IS acquired the data, analyzed the results, drafted the manuscript and critically reviewed the manuscript. MK and JL performed statistical analysis and analyzed the results. AC, MM, RB, FG, JC, ON, FE acquired the data and critically reviewed the manuscript.
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 Outside this work: JL reports grants from Stryker, Penumbra and Microvention. MM reports personal fees from Acticor Biotech, Air liquide, Amgen and Boerhinger.
Provenance and peer review Not commissioned; externally peer reviewed.
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