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Direct to embolectomy without IV tPA: the stage is set for a randomized controlled trial

In a recent commentary entitled ‘Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?’,1 we considered the advantages and disadvantages of administering intravenous tissue plasminogen activator (IV tPA) in patients also eligible for mechanical embolectomy. This generated much discussion, underscoring the topical nature of the question. Weber et al 2 have recently published an important contribution on this issue.

They retrospectively analyzed 283 consecutive patients treated with mechanical embolectomy in a tertiary neurovascular center over 14 months; data on prior IV tPA and functional outcome were available for 250 patients.2 When they compared patients treated with IV tPA and embolectomy (n=105) with patients receiving embolectomy alone (n=145), there was no significant difference in the rates of successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b/3, 73.8% vs 73.1%, p=0.952), symptomatic hemorrhage (5.9% vs 3.5%, p=0.387), and long term favorable outcome (modified Rankin Scale (mRS) score 0–2, 35.2% vs 40%, p=0.444). Therefore, prior use of …