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Intra-arterial Thrombolysis or Stent Placement During Endovascular Treatment for Acute Ischemic Stroke Leads to the Highest Recanalization Rate: Results of a Multicenter Retrospective Study

Gupta, Rishi MD*; Tayal, Ashis H MD§; Levy, Elad I MD¶; Cheng-Ching, Esteban MD‡; Rai, Ansaar MD‖; Liebeskind, David S MD#; Yoo, Albert J MD**; Hsu, Daniel P MD‡‡; Rymer, Marilyn M MD§§; Zaidat, Osama O MD¶¶; Lin, Ridwan MD‖‖; Natarajan, Sabareesh K MD, MS¶; Nogueira, Raul G MD*; Nanda, Ashish MD‡‡; Tian, Melissa RN§; Hao, Qing MD, PhD#; Abou-Chebl, Alex MD##; Kalia, Junaid S MD¶¶; Nguyen, Thanh N MD***; Chen, Michael MD‡‡‡; Jovin, Tudor G MD‖‖

doi: 10.1227/NEU.0b013e31820f156c
Research-Human-Clinical Studies: Editor's Choice

BACKGROUND: Reperfusion therapy for acute ischemic stroke (AIS) is rapidly evolving, with the development of multiple endovascular modalities that can be used alone or in combination.

OBJECTIVE: To determine which pharmacologic or mechanical modality may be associated with increased rates of recanalization.

METHODS: A cohort of 1122 patients with AIS involving the anterior circulation treated at 13 stroke centers underwent intra-arterial (IA) therapy within 8 hours of symptom onset. Demographic information, admission National Institutes of Health Stroke Scale (NIHSS), mechanical and pharmacologic treatments used, recanalization grade, and hemorrhagic complications were recorded.

RESULTS: The mean age was 67 ± 16 years and the median NIHSS was 17. The sites of arterial occlusion before treatment were M1 middle cerebral artery (MCA) in 561 (50%) patients, carotid terminus in 214 (19%) patients, M2 MCA in 171 (15%) patients, tandem occlusions in 141 (13%) patients, and isolated extracranial internal carotid artery occlusion in 35 (3%) patients. Therapeutic interventions included multimodal therapy in 584 (52%) patients, pharmacologic therapy only in 264 (24%) patients, and mechanical therapy only in 274 (24%) patients. Patients treated with multimodal therapy had a significantly higher Thrombolysis in Myocardial Infarction 2 or 3 recanalization rate (435 patients [74%]) compared with pharmacologic therapy only (160 patients, [61%]) or mechanical only therapy (173 patients [63%]), P < .001. In binary logistic regression modeling, independent predictors of Thrombolysis in Myocardial Infarction 2 or 3 recanalization were use of IA thrombolytic OR 1.58 (1.21-2.08), P < .001 and stent deployment 1.91 (1.23-2.96), P < .001.

CONCLUSION: Multimodal therapy has significantly higher recanalization rates compared with pharmacologic or mechanical therapy. Among the individual treatment modalities, stent deployment or IA thrombolytics increase the chance of recanalization.

*Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia; ‡The Cleveland Clinic Foundation, Cleveland, Ohio; §Allegheny General Hospital, Pittsburgh, Pennsylvania; ¶SUNY Buffalo, Buffalo, New York; ‖University of West Virginia, Morgantown, West Virginia; #for the UCLA Revascularization Investigators and UCLA Stroke Investigators, University of California Los Angeles, Los Angeles, California; **Massachusetts General Hospital, Boston, Massachusetts; ‡‡University Hospitals, Cleveland, Ohio; §§Saint Luke's Brain and Stroke Institute, Kansas City, Missouri; ¶¶Medical College of Wisconsin, Milwaukee, Wisconsin; ‖‖Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; ##University of Louisville Medical Center, Louisville, Kentucky; ***Boston University School of Medicine, Boston, Massachusetts; ‡‡‡Rush University Medical Center, Chicago, Illinois

Received, June 16, 2010.

Accepted, November 18, 2010.

Rishi Gupta and Ashis H. Tayal contributed equally to this work.

Correspondence: Rishi Gupta, MD, 49 Jesse Hill Jr Drive, SE, Emory University School of Medicine, Faculty Office Building, #393, Atlanta, GA 30303. E-mail:

Copyright © by the Congress of Neurological Surgeons