Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

Background and Purpose We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TLs) and whether using intraprocedural antiplatelet therapy (APT) influences MT’s safety with IVT treatment. Methods This is a sub-analysis of a pooled, international multicenter cohort of patients with acute anterior circulation TLs treated with MT. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2). Additional outcomes included hemorrhagic transformation (HT), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3), complete reperfusion (mTICI 3), favorable functional outcome (90-day modified Rankin score [mRS] 0-2), excellent functional outcome (90-day mRS 0-1), in-hospital mortality, and 90-days mortality. Results Of 691 patients, 599 were included (255 underwent IVT+MT and 344 MT alone). There was no difference in the risk of sICH (aOR=1.43; 95%CI:0.72–2.87; p= 0.308), PH2 (aOR=1.14; 95%CI:0.57– 2.28; p =0.705), and HT (aOR=0.92; 95%CI:0.54–1.57; p =0.751) between the IVT+MT and MT alone groups after adjusting for confounders. There was an IVT-by-intraprocedural APT interaction for sICH ( p interaction=0.031). Administration of IVT was associated with an increased risk of sICH in patients who received IV-APT (aOR=3.58; 95%CI:1.17–10.89; p= 0.025). The IVT+MT group had higher odds of 90-days mRS 0-2 (aOR=1.76; 95%CI:1.05–2.94; p= 0.030). The odds of successful reperfusion, complete reperfusion, 90-days mRS 0-1, in-hospital mortality, or 90-days mortality did not differ between the IVT+MT vs. MT alone groups. Conclusion Our study showed that the combination of IVT with MT for TL did not increase the overall risk of sICH, PH2, or overall HT independently of the cervical revascularization technique used. However, intraprocedural IV-ATP during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT prior to MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcome at 90 days. ### Competing Interest Statement Santiago Ortega-Gutierrez is consultant for Medtronic and Stryker. Edgar A. Samaniego is consultant for Medtronic and Rapid Medical. Colin Derdeyn is consultant for Penumbra, Nono, Rapid Medical Genae Americas, Pulse Therapeutics and Siemens Healthineers. The rest of the authors report no conflicts. Ameer E. Hassan is consultant/speaker for Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care and Galaxy Therapeutics; principal investigator of 2.Principal Investigator: COMPLETE study - Penumbra, LVO SYNCHRONISE - Viz.ai, Millipede Stroke Trial - Perfuze, RESCUE - ICAD - Medtronic; Steering Committee/Publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS. James E. Siegler reports speakers bureau for AstraZeneca. Dr. Divani received the following fundings: the University of New Mexico Center for Brain Recovery and Repair Center of Biomedical Research Excellence through Grant Number (NIH P20GM109089, Pilot PI), W81XWH-17-2-0053 (PI), 1R21NS130423-01 (PI) ### Funding Statement No funding to declare for the present study ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: University of Iowa IRB 202009106 I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Not Applicable Data not provided in the article because of space limitations may be shared (anonymized) at the request of any qualified investigator for purposes of replicating procedures and results.