Comparison of mechanical thrombectomy alone versus post-IV t-PA thrombectomy in acute large artery occlusion within 4.5 hours of symptom onset

Intravenous tissue plasminogen activator (IV t-PA) is commonly used as bridging therapy before mechanical thrombectomy (MT) in acute ischemic stroke. However, in practice, some patients undergo MT only after IV t-PA has been fully administered. This study aimed to compare clinical and radiological outcomes of MT only versus IV t-PA followed by MT within 4.5 hours of symptom onset. We retrospectively reviewed 190 patients with acute large artery occlusion treated with MT between January 2018 and December 2020. After excluding 53 patients ineligible for IV t-PA. A total of 137 patients were enrolled and categorized into two groups: MT only (n=82, 59.8%) and post-IV t-PA MT (n=55, 40.2%). The primary outcome was successful recanalization; the secondary outcome was a good clinical outcome at 90 days (3-month modified Rankin Scale (mRS) score of 0-2). The successful recanalization rates did not significantly differ between the MT-only and post-IV t-PA MT groups (92.7% vs. 89.1%, p=0.466). Good outcomes at 90 days were not statistically different between both groups (58.5% vs. 61.8%, p=0.701). Multivariable analysis identified baseline National Institutes of Health Stroke Scale (NIHSS) score (adjusted odds ratio (OR) 0.873; 95% confidence intervals (CI), 0.806-0.946; p<0.001) and door-to-puncture time (adjusted OR 0.987; 95% CI, 0.978-0.997; p=0.009) as independent predictors of outcome. In our study, MT alone yielded comparable outcomes to IV t-PA followed by MT in patients treated within 4.5 hours. Direct MT may be a reasonable treatment strategy.