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Direct Mechanical Thrombectomy Versus Combined Intravenous and Mechanical Thrombectomy in Large-Artery Anterior Circulation Stroke: A Topical Review

Intravenous thrombolysis (IVT) with recombinant intravenous (IV) tPA (tissue-type plasminogen activator) significantly improves the odds of good outcome after ischemic stroke when delivered within 4.5 hours of stroke onset, irrespective of age and over a broad range of stroke severity, and despite an increased risk of intracranial hemorrhage (ICH).1 Therefore, in the absence of contraindications, IVT is the standard therapy for all patients presenting with an acute ischemic stroke (AIS) within 4.5 hours after symptom onset.2 However, IVT has some important limitations, such as a narrow time window with a rapidly decreasing efficacy and a rapidly increasing number needed to treat,1 the overall increase of fatal ICH compared with placebo,1 a poor recanalization rate in patients with large thrombus burden,3 and various contraindications, such as pretreatment with oral anticoagulants and unclear time of symptom onset.

Endovascular stroke treatment (EVT) in combination with IVT (ie, bridging thrombolysis) has the potential to overcome some limitations of IVT, especially the poor recanalization rate of patients with large vessel occlusions (LVOs). Three randomized controlled trials (RCTs) published in 2013 failed to demonstrate superior clinical outcomes of EVT.4–6 However, since December 2014, 8 RCTs testing newer devices have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (with and without IV tPA) improves outcome in anterior circulation (AC) ischemic stroke patients with LVO compared with best medical treatment alone.7–14 These later trials used second-generation devices, required imaging confirmation of LVO, emphasized rapid time to reperfusion, and excluded patients with a priori high chance of futile recanalization (ie, patients with large areas of brain tissue who had already undergone infraction or patients with poor collaterals). MT with stent retriever in addition to IVT is now the recommended treatment for AIS patients with …