Letter by Katsanos and Tsivgoulis Regarding Article, “Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment”

HomeStrokeVol. 52, No. 1Letter by Katsanos and Tsivgoulis Regarding Article, “Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBLetter by Katsanos and Tsivgoulis Regarding Article, “Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment” Aristeidis H. Katsanos, MD and Georgios Tsivgoulis, MD Aristeidis H. KatsanosAristeidis H. Katsanos Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K.). Search for more papers by this author and Georgios TsivgoulisGeorgios Tsivgoulis https://orcid.org/0000-0002-0640-3797 Second Department of Neurology, “Attikon” Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.). Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.). Search for more papers by this author Originally published28 Dec 2020https://doi.org/10.1161/STROKEAHA.120.032471Stroke. 2021;52:e35–e36To the Editor:We read with interest the letter by Flint et al,1 assessing the risk of distal embolization from intravenous tPA (tissue-type plasminogen activator) administration before endovascular treatment (EVT) of patients with acute ischemic stroke due to a large vessel occlusion. By retrospectively analyzing data from an electronic medical record database, authors identified 85 patients with acute ischemic stroke due to large vessel occlusion treated with direct EVT and 242 patients with intravenous tPA followed by EVT.1Authors report that distal embolization occurred in a total of 63 cases (20.1%), with the location of distal embolization being to an M3 segment or beyond in 23.8% of the cases and beyond the proximal M2 segment in 54.2% of the cases.1 Distal embolization rates were found to be higher in patients who received tPA before EVT (24.9%) compared with those who were treated with direct EVT (7.1%).1 Despite the higher rates of distal embolization in tPA pretreated patients and the inability to perform EVT due to final clot location in 41.3% of the patients experiencing distal embolization, Flint et al1 report that tPA administration before EVT and successful recanalization following EVT were the only predictors that were significantly associated with functional independence at 3 months. The association of tPA pretreatment with better functional outcomes in patients with large vessel occlusion treated with EVT has also been highlighted by previous observational cohort studies and summarized in a recent meta-analysis from our group.2 As previous reports have additionally suggested that tPA administration is associated with a higher chance of successful recanalization following EVT,2 we would welcome a multivariable analysis addressing further this outcome from authors. On the same line and taking into account both the observational and randomized controlled clinical trial evidence suggesting no increased rates of symptomatic intracerebral hemorrhage after EVT for patients receiving tPA pretreatment,2,3 Flint et al may also consider providing absolute rates and adjusted associations on the outcome of symptomatic intracerebral hemorrhage after EVT stratified by the history of tPA pretreatment.Flint et al1 report that 5.4% of the patients who received tPA had significant symptom improvement that finally averted the need for EVT and catheter angiogram. These patients were not accounted in the cases of complete recanalization, as no catheter angiogram was available, leading to an overt underestimation of patients achieving complete recanalization following tPA of only 0.9%. Data from randomized controlled clinical trials converge that tPA treatment is associated with successful recanalization and avert in the need for EVT in twice more cases (10%) than the percentage reported by Flint et al.4,5 Therefore, we consider the percentage of cases with averted EVT due to tPA-related clinical improvement non-negligible and respectfully disagree with the authors’ conclusion that the proportion of tPA-treated subjects experiencing clinical improvement or complete recanalization is small.The work by Flint et al builds up the evidence that tPA administration does not delay EVT initiation, while it can induce successful reperfusion and potentially be related with better patient outcomes. We still cannot see any sound evidence to withhold this treatment option from eligible patients.Sources of FundingNone.DisclosuresNone.FootnotesThis article was sent to Marc Fisher, Senior Consulting Editor, for editorial decision and final disposition.For Sources of Funding and Disclosures, see page e36.References1. Flint AC, Avins AL, Eaton A, Uong S, Cullen SP, Hsu DP, Edwards NJ, Reddy PA, Klingman JG, Rao VA, et al.. Risk of distal embolization from tPA (tissue-type plasminogen activator) administration prior to endovascular stroke treatment.Stroke. 2020; 51:2697–2704. doi: 10.1161/STROKEAHA.120.029025LinkGoogle Scholar2. Katsanos AH, Malhotra K, Goyal N, Arthur A, Schellinger PD, Köhrmann M, Krogias C, Turc G, Magoufis G, Leys D, et al.. Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions.Ann Neurol. 2019; 86:395–406. doi: 10.1002/ana.25544CrossrefMedlineGoogle Scholar3. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, Peng Y, Han H, Wang J, Wang S, et al.; DIRECT-MT Investigators. Endovascular thrombectomy with or without intravenous alteplase in acute stroke.N Engl J Med. 2020; 382:1981–1993. doi: 10.1056/NEJMoa2001123CrossrefMedlineGoogle Scholar4. Tsivgoulis G, Katsanos AH, Schellinger PD, Köhrmann M, Varelas P, Magoufis G, Paciaroni M, Caso V, Alexandrov AW, Gurol E, et al.. Successful reperfusion with intravenous thrombolysis preceding mechanical thrombectomy in large-vessel occlusions.Stroke. 2018; 49:232–235. doi: 10.1161/STROKEAHA.117.019261LinkGoogle Scholar5. Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, Yan B, Bush SJ, Dewey HM, Thijs V, et al.; EXTEND-IA TNK Investigators. Tenecteplase versus alteplase before thrombectomy for ischemic stroke.N Engl J Med. 2018; 378:1573–1582. doi: 10.1056/NEJMoa1716405CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2021Vol 52, Issue 1Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.120.032471PMID: 33370177 Originally publishedDecember 28, 2020 PDF download Advertisement SubjectsIschemic Stroke