Alteplase before mechanical thrombectomy: which patients benefit from this bridging therapy?

Stroke is a leading cause of death and disability. In patients with ischemic stroke caused by large intracranial artery occlusion, treatment options include intravenous thrombolysis and mechanical thrombectomy. While tenecteplase is gaining favor, alteplase remains widely used, and its role as bridging therapy (BT) before thrombectomy is still debated. To identify which patients with ischemic stroke benefit most from intravenous alteplase prior to mechanical thrombectomy, focusing on functional recovery and mortality within 90 days.

We analyzed prospectively collected observational data from 292 patients with large-vessel ischemic stroke treated with thrombectomy at University Clinical Hospital No. 1 of the Pomeranian Medical University in Szczecin between May 2019 and December 2021. Of these, 164 received bridging intravenous alteplase and 128 underwent thrombectomy alone. Clinical, demographic, and procedural characteristics were compared. Primary outcomes were functional independence (modified Rankin Scale [mRS] ≤ 2) at discharge, 30 days, and 90 days. Secondary outcomes included neurological recovery (National Institutes of Health Stroke Scale [NIHSS]) and mortality at 90 days.

Patients receiving alteplase were significantly younger and had fewer comorbidities compared to those treated with thrombectomy alone. Functional outcomes favored the alteplase group: 42.7% regained independence by 90 days versus 39.1% in the thrombectomy-only group, but the difference was not statistically significant. Neurological deficit improved in both groups with comparable trajectories. Subgroup analyses indicated that patients < 80 years old and those treated with alteplase within 3 hours of symptom onset had significantly higher rates of independence at 90 days. Smoking and alcohol abuse were unexpectedly associated with improved outcomes, while atrial fibrillation tended to predict poorer recovery. Mortality rates were similar between groups (39.6% vs. 37.5%, p = 0.66), with no excess risk of in-hospital or early death from alteplase administration.

Bridging therapy with alteplase before thrombectomy was safe and associated with a modest improvement in functional outcomes compared with thrombectomy alone. The greatest benefit was observed in patients under 80 years old and in those treated within 3 hours of symptom onset. These findings support the continued selective use of alteplase in BT without increasing mortality risk.