Safety and efficacy of intravenous tPA after successful thrombectomy for large vessel occlusion: a retrospective study.

INTRODUCTION

This study aimed to evaluate the efficacy and safety of adjunctive intravenous (IV) tissue plasminogen activator (tPA) administration following successful mechanical thrombectomy in patients with acute ischemic stroke caused by large vessel occlusion (LVO).

METHODS

This single-center retrospective study included patients with anterior circulation LVO who achieved successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) after endovascular thrombectomy (EVT) between January 2021 and December 2024. Beginning in December 2022, 25% of the standard IV tPA dose (0.6 mg/kg) was administered immediately after successful recanalization (post-IV tPA group), in addition to the standard pre-EVT 75% dose. Parenchymal blood volume (PBV) ratios were assessed using flat-panel detector computed tomography before and after EVT. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), and 90-day mortality.

RESULTS

Fifty-five patients met inclusion criteria (post-IV tPA, n = 21; standard care, n = 34). The post-IV tPA group showed significantly higher post-EVT PBV ratios (1.45 vs. 1.20, p = 0.03) and greater ΔPBV (2.45 vs. 1.81, p = 0.011). Good functional outcomes (mRS 0-2 at 90 days) were more frequent in the post-IV tPA group (61.9% vs. 29.4%, p = 0.025). No significant differences were seen in overall ICH (14.3% vs. 14.7%, p = 1.00), sICH (9.5% vs. 8.8%, p = 1.00), or 90-day mortality (0% vs. 9%, p = 0.54). Patients who exhibited lesion growth on diffusion-weighted imaging showed significantly lower post-EVT PBV and ΔPBV ratios (p = 0.002 and 0.0134, respectively). In subgroup analysis, longer onset-to-recanalization time was associated with hemorrhagic events in the post-IV tPA group (307 min vs. 226 min, p = 0.04).

CONCLUSION

Adjunctive IV tPA administration following successful EVT may improve microvascular reperfusion and functional outcomes without increasing hemorrhagic complications, although careful patient selection is warranted. Due to study limitations, results are hypothesis-generating and require further validation in future prospective randomized trials.