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Updated: Apr 22, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Intra-Arterial Thrombolytic vs. Mechanical Thrombectomy in Distal Medium Middle Cerebral Artery Acute Ischemic
Hamza Adel Salim1,2, Benjamin Pulli3, Vivek Yedavalli4
1Johns Hopkins Medical Center, Baltimore, United States. Hamza.sleeem@gmail.com.
Background:
Optimal treatment for acute ischemic stroke due to distal medium-vessel occlusion (DMVO) in the middle cerebral artery (MCA) remains uncertain. While mechanical thrombectomy (MT) may pose higher risks in DMVO, intra-arterial thrombolysis (IAT)-with or without intravenous thrombolysis (IVT)-could be a safer alternative.
Purpose:
To compare functional outcomes and safety profiles of IAT versus MT in acute ischemic stroke caused by MCA DMVO (M2-M4 segments).
Methods:
We performed a retrospective, propensity score-matched study across 37 centers (Asia, Europe, North America) using the MAD-MT registry. Patients with MCA DMVO (M2-M4) treated with IAT or MT (with/without IVT) were included. Propensity score matching adjusted for confounders. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0-1 at 90 days).
Results:
After matching, 184 patients were analyzed (19 IAT, 165 MT). Baseline characteristics were balanced. At 90 days, excellent functional outcomes occurred in 38% (IAT) versus 21% (MT) (P = 0.20). Functional independence (mRS 0-2) rates were 50% (IAT) versus 40% (MT) (P = 0.42). Mortality was comparable (13% vs. 17%). Successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3) was higher with MT (90% vs. 68%; P = 0.02), but symptomatic intracranial hemorrhage occurred only with MT (6.7% vs. 0%; P = 0.60).
Conclusion:
For MCA DMVO, IAT showed similar functional outcomes and numerically fewer safety events than MT despite lower recanalization rates. These findings should be interpreted cautiously, given the small IAT sample size and require validation in larger prospective studies.
Insights
Intra-arterial thrombolysis (IAT) for acute ischemic stroke in distal medium-vessel occlusions (DMVO) of the middle cerebral artery (MCA) showed similar functional outcomes to mechanical thrombectomy (MT). IAT also had numerically fewer safety events, despite lower recanalization rates.
Area of Science:
- Neurology
- Interventional Neurology
- Stroke Medicine
Background:
- Optimal treatment for acute ischemic stroke due to distal medium-vessel occlusion (DMVO) in the middle cerebral artery (MCA) remains uncertain.
- Mechanical thrombectomy (MT) may carry higher risks in DMVO, suggesting intra-arterial thrombolysis (IAT) as a potentially safer alternative.
Purpose of the Study:
- To compare functional outcomes and safety profiles of IAT versus MT in acute ischemic stroke caused by MCA DMVO (M2-M4 segments).
Main Methods:
- A retrospective, propensity score-matched study was conducted across 37 centers using the MAD-MT registry.
- Patients with MCA DMVO (M2-M4) treated with IAT or MT (with/without IVT) were included.
- Propensity score matching adjusted for confounders, with excellent functional outcome (mRS 0-1 at 90 days) as the primary outcome.
Main Results:
- After matching, 184 patients (19 IAT, 165 MT) were analyzed with balanced baseline characteristics.
- Excellent functional outcomes (mRS 0-1) at 90 days were 38% for IAT vs. 21% for MT (P=0.20).
- Successful reperfusion (mTICI 2b-3) was higher with MT (90% vs. 68%; P=0.02), but symptomatic intracranial hemorrhage occurred only with MT (6.7% vs. 0%; P=0.60).
Conclusions:
- For MCA DMVO, IAT demonstrated similar functional outcomes and numerically fewer safety events compared to MT, despite lower recanalization rates.
- These findings require cautious interpretation due to the small IAT sample size.
- Larger prospective studies are needed to validate these results.
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