Intravenous recombinant tissue plasminogen activator and neuroendovascular therapies in acute ischemic stroke patients: utility of combined therapy

Objective: To assess the efficacy and safety of intravenous recombinant tissue plasminogen activator (IV-tPA) therapy and combining IV-tPA with neuroendovascular therapy (combined therapy [ComT]) in acute ischemic stroke. Methods: Among 481 consecutive patients with acute ischemic stroke, we investigated the recanalization rate, clinical outcomes three months after stroke onset, and the incidence of symptomatic intracranial hemorrhage (sICH) in 33 patients who received IV-tPA therapy (0.6 mg/kg for 60 minutes). We performed ComT in 9 of these 33 patients who satisfied the treatment indications. Results: The recanalization rate immediately after IV-tPA therapy was 39.3% in 28 of the 33 patients, i.e., excluding the five with small-artery occlusions. In the ComT group, the rate of recanalization was 44.4% (4 of the 9 patients). Good and intermediate clinical outcomes (0-3 points on the modified Rankin Scale at three months) were seen in 17 patients (51.5%), and sICH occurred in only one (3.0%). Rates of recanalization (immediately after IV-tPA therapy/ComT) in the internal carotid artery (ICA), the proximal middle cerebral artery (MCA), the distal MCA, and the basilar artery were 0%/ 50%, 42.9%/ 50%, 77.8%/ - and 50%/ 0%, respectively. Among those with ICA and proximal MCA occlusions, a large number of patients had poor outcomes. In fact, the only patients with good outcomes were in the recanalized group. Conclusion: IV-tPA therapy was not particularly useful in patients with ICA occlusion. However, if used according to strict indications, ComT can be performed safely and might improve the recanalization rate and clinical outcomes of patients with ICA occlusion.