Safety and Efficacy of Intravenous Alteplase before Endovascular Thrombectomy: A Pooled Analysis with Focus on the Elderly

Asaf Honig, Hen Hallevi, Naaem Simaan, Tzvika Sacagiu, Estelle Seyman, Andrei Filioglo, Moshe J. Gomori, Ofer Rotschild, Tali Jonas-Kimchi, Udi Sadeh, Anat Horev, Ronen R. Leker, José E. Cohen, Jeremy Molad

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Current guidelines advocate intravenous thrombolysis (IVT) prior to endovascular thrombec-tomy (EVT) for all patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We evaluated outcomes with and without IVT pretreatment. Our institutional protocols allow AIS patients presenting early (<4 h from onset or last seen normal) who have an Alberta Stroke Program Early CT Score (ASPECTS) ≥6 to undergo EVT without IVT pretreatment if the endovascular team is in the hospital (direct EVT). Rates of recanalization and hemorrhagic transformation (HT) and neurological outcomes were retrospectively compared in consecutive patients undergoing IVT+EVT vs. direct EVT with subanalyses in those ≥80 years and ≥85 years. In the overall cohort (IVT+EVT = 147, direct EVT = 162), and in subsets of patients ≥80 years (IVT+EVT = 51, direct EVT = 50) and ≥85 years (IVT+EVT = 19, direct EVT = 32), the IVT+EVT cohort and the direct EVT group had similar baseline characteristics, underwent EVT after a comparable interval from symptom onset, and reached similar rates of target vessel recanalization. No differences were observed in the HT frequency, or in disability at discharge or after 90 days. Patients receiving direct EVT underwent more stenting of the carotid artery due to stenosis during the EVT procedure (22% vs. 6%, p = 0.001). Direct EVT and IVT+EVT had comparable neurological outcomes in the overall cohort and in the subgroups of patients ≥80 and ≥85 years, suggesting that direct EVT should be considered in patients with an elevated risk for HT.

Original languageEnglish
Article number3681
JournalJournal of Clinical Medicine
Issue number13
StatePublished - 1 Jul 2022
Externally publishedYes


  • acute ischemic stroke
  • elderly
  • endovascular thrombectomy
  • intravenous alteplase

ASJC Scopus subject areas

  • General Medicine


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