TY - JOUR T1 - Early recanalization with intravenous thrombolysis before mechanical thrombectomy: considerations to explore with tenecteplase JF - Journal of NeuroInterventional Surgery JO - J NeuroIntervent Surg DO - 10.1136/jnis-2022-019981 SP - jnis-2022-019981 AU - Philipp Hendrix AU - Clemens M Schirmer Y1 - 2022/12/23 UR - http://jnis.bmj.com/content/early/2022/12/22/jnis-2022-019981.abstract N2 - Time is brain. Hence, timely reperfusion in emergent large vessel occlusion (LVO) stroke is critical for favorable outcomes. Intravenous thrombolysis with alteplase (TPA) before mechanical thrombectomy (MT) for emergent LVO stroke is associated with significantly higher rates of preinterventional reperfusion than MT alone. Recent post hoc analyses of SWIFT-DIRECT and DIRECT-MT have shown that times longer than 30 min since TPA administration are associated with increased reperfusion rates.1 2 The incremental increase of reperfusion rates with longer times since TPA administration underpins TPA’s time dependence to exert clot dissolution in emergent LVO strokes.3 4Distinct clot characteristics, such as shorter thrombus length, more distal location in the anterior circulation, and lesser clot burden (ie, higher clot burden score), have been associated with clot susceptibility to TPA-lysis and hence reperfusion rates.5 6 Overall, reperfusion rates before MT with and without TPA vary substantially in the current literature. While some studies report spontaneous reperfusion before TPA administration in the range of 0.7–13%, following TPA administration, reperfusion rates vary from 5.4% to 41%.1 2 4 5 7–12 Notably, the wide ranges of reperfusion rates with TPA administration in the setting of LVO stroke are attributable to prospective and retrospective studies employing different definitions of reperfusion, modalities to assess reperfusion (CT angiography, CT perfusion, digital subtraction angiography), and selection criteria and study variables. In … ER -