Primary Thrombectomy in tPA (Tissue-Type Plasminogen Activator) Eligible Stroke Patients With Proximal Intracranial Occlusions

A 56-year-old diabetic man presented to the emergency room 45 minutes after right-sided hemiplegia and global aphasia. National Institutes of Health Stroke Scale score, 20; ASPECTS score (Alberta Stroke Program Early CT Score), 9, on computed tomographic (CT) scan; and CT angiography showed terminal ICA T occlusion. Both angio suite and interventionalist are available. No contraindication for IV tPA (tissue-type plasminogen activator).Would you consider transferring the patient directly to the angio suite for thrombectomy skipping IV tPA?Primary thrombectomy (PT) versus IV tPA followed by thrombectomy in stroke patients with proximal intracranial occlusions. Urs Fischer and Johannes Kaesmacheru003e “It seems that perfection is attained, not when there is nothing more to add, but when there is nothing more to take away.” u003e u003e Antoine de Saint ExuperyDo we harm the patient when we take the tPA away? The 2 most important considerations in favor of the bridging approach are preinterventional recanalization obviating the need for thrombectomy and the increased odds for recanalization if the occlusion site is not accessible or reperfusion is not achieved by mechanical thrombectomy (MT). Given the proximal occlusion site, the presumingly high thrombus burden and the short tPA-to-groin puncture interval outlined in the scenario, the odds for all of the latter are negligible (≈3–4/100).1 In particular, it seems unlikely that tPA will lyse hard thrombi, which are not retrievable with stent retrievers. A recent meta-analysis has suggested that tPA may promote good angiographic results2; however, the interpretation is severely limited by selection and publication bias and not supported by recent post hoc analyses of randomized controlled clinical trials (RCTs) or large prospective cohorts.3,4 Until now, there is no conclusive evidence: neither that tPA promotes good angiographic results in subsequent MT,3,4 nor that the effect size of MT is altered by pretreatment with …