When lysis moves the target: thrombus migration after tenecteplase and its impact on endovascular recanalization

Thrombus migration (TM) is more common after intravenous thrombolysis (IVT) with tenecteplase (TNK) compared with alteplase. We aimed to determine TM impact over endovascular thrombectomy (EVT) results in patients undergoing TNK-IVT for acute ischemic stroke.

We retrospectively included all patients with large vessel occlusion of the anterior circulation, treated with TNK-IVT and eligible for EVT between January 2015 and February 2021, from a large observational TNK registry (Tenecteplase Treatment in Ischemic Stroke-TETRIS). TM was defined by a distal shift of the occlusion site between initial non-invasive imaging and digital subtraction angiography (DSA) before endovascular thrombectomy. We compared angiographic (revised Treatment In Cerebral Infarction-rTICI) and functional (modified Rankin Scale-mRS) outcomes in cases of TM versus no TM.

Out of 580 enrolled patients, TM occurred between the initial imaging and the first DSA run in 209 (36.0%) of them. TM led to EVT being impossible to perform in 26% of cases (vs 4% in absence of TM). Longer needle-to-groin time and shorter susceptibility vessel sign length were independently associated with TM. Rates of successful recanalization (rTICI 2b/3) were similar between groups. However, we observed higher rates of excellent (rTICI 2c/3) (64.8% vs 51.7%, P=0.02) and complete reperfusion (rTICI 3) (46.6% vs 27.8%, P<0.001) in the absence of TM, but with no impact on clinical outcomes (mRS 0-2=44.7% in the non-migration group vs 47.1% in the migration group; P=0.59).

TM is a frequent and time-related consequence of TNK-IVT that hinders recanalization rates but does not impact functional outcomes.