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Original research
Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct
  1. Mohammad Anadani1,
  2. Eyad Almallouhi1,
  3. Ilko Maier2,
  4. Sami Al Kasab1,
  5. Pascal Jabbour3,
  6. Joon-tae Kim4,
  7. Stacey Q Wolfe5,
  8. Ansaar Rai6,
  9. Robert M Starke7,
  10. Marios-Nikos Psychogios8,
  11. Edgar A Samaniego9,
  12. Adam S Arthur10,11,
  13. Shinichi Yoshimura12,
  14. Hugo Cuellar13,
  15. Brian M Howard14,15,
  16. Ali Alawieh14,
  17. Isabel Fragata16,
  18. Adam J Polifka17,
  19. Justin R Mascitelli18,
  20. Joshua W Osbun19,
  21. Charles Matouk20,
  22. Min S Park21,
  23. Michael R Levitt22,
  24. Travis M Dumont23,
  25. Richard Williamson24,
  26. Alejandro M Spiotta1
  1. 1Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  2. 2Neurology, University Medicine Goettingen, Goettingen, Germany
  3. 3Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  4. 4Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
  5. 5Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  6. 6Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
  7. 7Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  8. 8Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  9. 9Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  10. 10Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  11. 11Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  12. 12Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
  13. 13Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
  14. 14Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  15. 15Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
  16. 16Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  17. 17Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  18. 18Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  19. 19Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  20. 20Neurosurgery, Yale University, New Haven, Connecticut, USA
  21. 21Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  22. 22Neurological Surgery, University of Washington, Seattle, Washington, USA
  23. 23Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  24. 24Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Alejandro M Spiotta, Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA; spiotta{at}; Dr Mohammad Anadani, Neurosurgery, Medical University of South Carolina, Charleston, SC, USA; anadani{at}


Background The safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.

Methods This is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.

Results A total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0–2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.

Conclusion Pretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

  • Stroke
  • Thrombectomy
  • CT
  • Thrombolysis

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @PascalJabbourMD, @Starke_neurosurgery, @esamaniego, @AdamArthurMD, @BrianHoward_MD, @DrMichaelLevitt

  • Contributors Substantial contributions to the conception or design of the work: MA, AMS. Acquisition, analysis, and interpretation of the data for the work: all authors. Drafting the work or revising it critically for important intellectual content: MA, EA, AA, ML, MS, AMS. MA and AMS accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding STAR receives funding support from Stryker, Medtronic, Penumbra and Rapid AI.

  • Competing interests MRL: Grants from the NIH (R01NS105692, R01NS088072, U24NS100654, UL1TR002319, R25NS079200) and the American Heart Association (18CDA34110295). Unrestricted educational grants from Medtronic, Stryker and Philips Volcano. Consultant for Medtronic. Minor equity/ownership interest in Proprio, Cerebrotech, Synchron. Adviser to Metis Innovative. AMS: Research support from Penumbra, Stryker, Medtronic, and Siemens. Consultant for Penumbra, Stryker, Terumo, and Arsenal. RMS: Grants from the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, the NIH (R01NS111119-01A1, UL1TR002736, KL2TR002737), the National Center for Advancing Translational Sciences, the National Institute on Minority Health and Health Disparities, and Medtronic. Consultant for Penumbra, Abbott, Medtronic, InNeuroCo and Cerenovus. JRM is on the editorial board of JNIS.

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

  • © Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.