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Area of Science:

  • Neuroscience
  • Cardiovascular Medicine
  • Radiology

Background:

  • Delayed reperfusion (DR) occurs in over half of ischemic stroke patients with incomplete reperfusion (eTICI <3) after endovascular treatment.
  • DR is linked to favorable clinical outcomes, but the role of intravenous thrombolysis (IVT) in its occurrence is not well understood.

Purpose of the Study:

  • To investigate the treatment effect of IVT on the rates of delayed reperfusion (DR) in patients undergoing endovascular therapy for ischemic stroke.

Main Methods:

  • Pooled data from 3 RCTs and 2 stroke centers analyzed for patients with eTICI 2a-2c and 24-hour perfusion imaging.
  • Primary outcome: presence of DR on 24-hour imaging, defined as absence of focal perfusion deficit despite incomplete angiographic reperfusion.
  • Target trial emulation used to address confounding in observational data and assess the causal effect of IVT timing.

Main Results:

  • Of 832 patients, 61% exhibited DR. IVT showed an independent treatment effect on DR (sRR 1.1, 95% CI 1.0-1.3).
  • Among IVT recipients, shorter time from IVT administration to intervention end was causally associated with increased DR (sRR 0.93%, 95% CI 0.87-0.98 per hour increase).
  • This effect was observed when therapeutic thrombolytic concentrations were likely present during recanalization despite persistent distal occlusions.

Conclusions:

  • IVT has an independent treatment effect on DR in ischemic stroke patients with incomplete reperfusion post-thrombectomy.
  • The timing of IVT relative to the endovascular intervention significantly influences the likelihood of achieving DR.
  • These findings highlight the importance of IVT in optimizing reperfusion strategies for stroke patients.