Background:
Whether IV tPA has adjunctive benefit to endovascular thrombectomy (EVT) is unclear.
Methods:
In a prospective multicenter cohort study of imaging selection for EVT (SELECT), patients who received IV tPA vs. no IV tPA were compared stratified by stroke severity and ischemic core size (rCBF<30%).
Results:
Of 361 enrolled, 285 received EVT; 226 presented within 4.5 hrs, 162 (72%) received IV tPA. IV tPA patients had lower median ASPECTS (8 vs 9, p=0.007) and larger ischemic core size (11.4 (1.5-37) vs 3.9 (0-32.15), p=0.042, otherwise similar at baseline. There were no delays in EVT delivery associated with tPA: median time (IQR) from arrival to groin puncture 95.0 min (66.0, 118.0) tPA vs 81.5 (63.5, 107.5) no tPA, p=0.21. IV tPA use was associated with higher mRS 0-2 rates (57% vs 44%), aOR 2.02 (95% CI 1.01-4.03, p=0.046) after adjustment for baseline differences with a shift towards better outcomes on all mRS levels (cOR 2.06, 95% CI 1.18-3.59, p=0.01) with lower mortality (11% vs 22%, p=0.026) and similar sICH rates (and 6% vs 6%, p=1.0). In patients with NIHSS <15, IV tPA was associated with higher mRS 0-2 (tPA 83% vs no tPA 50%, aOR 4.53, 95%CI 1.48-13.80, p=0.008) with a shift towards better outcomes (adj cOR 5.44, 95% CI 2.16-13.70, p<0.001) while with NIHSS≥15 there was no adjunctive benefit of IV tPA (tPA 42% vs no tPA 38%, aOR 1.05, 95%CI 0.40-2.74, p=0.92) or shift (adj cOR: 1.32, 95% CI 0.61-2.86, p=0.48) with an interaction between IV tPA effect on EVT outcome with NIHSS (p=0.04) Fig A. Similarly, in ischemic core < 50 cc (62% vs. 46%, aOR 1.96, 95%CI 0.96-3.99, p=0.06; adj cOR 2.03, 95% CI 1.13-3.66, p=0.018) as compared to core ≥ 50cc (tPA 26% vs no tPA 25% P=1.0) with an interaction between IV tPA effect on EVT outcome with core size (p=0.037) Fig B.
Conclusion:
IV tPA did not result in thrombectomy delivery delays and may result in better outcomes. Patients with less severe strokes and smaller infarct size had a stronger association between the use of IV tPA and favorable outcomes.
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