Pros and cons of bridging therapy
| Potential harm | Effect | Potential benefit | Effect |
|---|---|---|---|
| IV tPA cost | Adds to procedural cost | ||
| Delay to EVT initiation29 | Later median onset to reperfusion resulting in worse outcomes | ||
| Proximal thrombus migration:43 vertebral to basilar or extracranial ICA to ICA T or M1 | Neurologic deterioration and more severe/extensive ischemia | ||
| IV tPA associated allergic reactions (1%)44 such as angioedema/hypotension and anaphylactoid reaction | During IV tPA infusion/EVT procedure which may worsen ischemia or require intubation/prolonged ICU stay | ||
| Ultra-early reperfusion by first angiography run (5–10%),9 11 21 especially if short thrombi21/residual flow21/occult antegrade flow45 | High rates of good/excellent clinical outcomes for this subpopulation | ||
| Distal thrombus migration:46 47 M1 to distal M2 or beyond | Early neurologic improvement | ||
| Softens thrombus for mechanical thrombectomy | Fewer passes of stent devices22/less cost; shorter procedure time/better outcomes48 | ||
| IV tPA reperfusion of persisting distal emboli post EVT procedure | Better outcomes since more complete reperfusion (TICI 3) | ||
| Higher chance of reperfusion when no EVT access to thrombus (recanalization at 2–8 h: 37% IV tPA vs 7% no IV tPA9) | Higher proportion with early reperfusion translating to better outcomes | ||
| Tandem extracranial and intracranial occlusions may require stenting during EVT and immediate antiplatelet therapy | More symptomatic intracranial hemorrhage (10%)49 | ||
| IV tPA-related blood brain barrier breakdown50 and coagulopathy51 | More symptomatic parenchymal hemorrhage within infarct | ||
| IV tPA-related coagulopathy51 and small vessel fragility52 | More large symptomatic extra-ischemic parenchymal hemorrhage (1–2%)52 | ||
| IV tPA-related coagulopathy51 | Puncture site hematoma (1–2%)9 | ||
| IV tPA-related coagulopathy51 | Major systemic bleeding (1%)44 | ||
| IV tPA lysis of left atrial appendage53 or other proximal thrombus | Early stroke recurrence54 or multiple systemic emboli55 | ||
| IV tPA-related neurotoxicity in animal models56 | More neuronal loss | ||
EVT, endovascular therapy; ICA, internal carotid artery; IV, intravenous; tPA, tissue plasminogen activator.