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Time is brain. Hence, timely reperfusion in emergent large vessel occlusion (LVO) stroke is critical for favorable outcomes. Intravenous thrombolysis with alteplase (TPA) before mechanical thrombectomy (MT) for emergent LVO stroke is associated with significantly higher rates of preinterventional reperfusion than MT alone. Recent post hoc analyses of SWIFT-DIRECT and DIRECT-MT have shown that times longer than 30 min since TPA administration are associated with increased reperfusion rates.1 2 The incremental increase of reperfusion rates with longer times since TPA administration underpins TPA’s time dependence to exert clot dissolution in emergent LVO strokes.3 4
Distinct clot characteristics, such as shorter thrombus length, more distal location in the anterior circulation, and lesser clot burden (ie, higher clot burden score), have been associated with clot susceptibility to TPA-lysis and hence reperfusion rates.5 6 Overall, reperfusion rates before MT with and without TPA vary substantially in the current literature. While some studies report spontaneous reperfusion before TPA administration in the range of 0.7–13%, following TPA administration, reperfusion rates vary from 5.4% to 41%.1 2 4 5 7–12 Notably, the wide ranges of reperfusion rates with TPA administration in the setting of LVO stroke are attributable to prospective and retrospective studies employing different definitions of reperfusion, modalities to assess reperfusion (CT angiography, CT perfusion, digital subtraction angiography), and selection criteria and study variables. In …
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Contributors PH: conception and design of the work, data collection, and interpretation, drafting of the article, final approval of the version to be published. PH, CS: data interpretation and critical revision of the article, final approval of the version to be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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