Adjunctive intra-arterial thrombolysis after thrombectomy: Findings from the RITE registry

Samar Eshetawe; Alaa Hijji; Sarah Almejaiwl; Mohammad Alqahtani; Fawaz F Alotaibi; Saida Mohammad; Hani Alabdely; Abdelmajeed Alanazi; Nouf Almansour; Abdullah Alrashed; Riyadh Alakili; Ammar AlKawi; Abdulrahman A Alreshaid; Mohamed AlZawahmah; Adel AlHazzani; Ashfaq Shuaib; Anas Alrohimi; Fahad S Al-Ajlan

doi:10.1177/15910199251343400

Adjunctive intra-arterial thrombolysis after thrombectomy: Findings from the RITE registry

Interv Neuroradiol. 2025 Jun 2:15910199251343400. doi: 10.1177/15910199251343400. Online ahead of print.

Authors

Samar Eshetawe¹, Alaa Hijji¹, Sarah Almejaiwl², Mohammad Alqahtani^{1

3}, Fawaz F Alotaibi¹, Saida Mohammad⁴, Hani Alabdely⁴, Abdelmajeed Alanazi⁴, Nouf Almansour⁴, Abdullah Alrashed⁵, Riyadh Alakili⁵, Ammar AlKawi^{1

6}, Abdulrahman A Alreshaid^{1

6}, Mohamed AlZawahmah^{1

6}, Adel AlHazzani^{1

6}, Ashfaq Shuaib⁷, Anas Alrohimi^{1

8}, Fahad S Al-Ajlan^{1

6}

Affiliations

¹ Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
² Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
³ Armed Forces Hospital Southern Region (AFHSR), Khamis Mushait, Saudi Arabia.
⁴ Department of Neurology, King Saud Medical City, Riyadh, Saudi Arabia.
⁵ Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
⁶ Alfaisal University, Riyadh, Saudi Arabia.
⁷ Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada.
⁸ Department of Medicine, Division of Neurology, King Saud University, Riyadh, Saudi Arabia.

Abstract

BackgroundDespite the excellent recanalization rates following thrombectomy, significantly fewer patients have favorable outcomes. Impaired reperfusion of the microcirculation caused by distal thrombi could contribute to that, and adjunctive intraarterial thrombolysis such as alteplase (IA-tPA) might improve outcomes. We assessed the impact of adjunctive IA-tPA following thrombectomy with TICI score $\geq$ 2A on functional outcomes and reperfusion status.MethodsA retrospective analysis of patients with LVO ischemic stroke who underwent EVT. Patients were dichotomized into those who received EVT + IA-tPA vs EVT alone. Primary outcomes were favorable functional outcome (90-day mRS 0-2), and 90-day home-time.Results354 patients were included, of which 133 (37.6%) were treated with EVT + IA-tPA and 221 (62.4%) were treated with EVT alone. Baseline characteristics were similar in both groups. The non-IA-tPA group had a significant proportion of patients with higher baseline TICI scores (P < 0.0001). There was no significant difference in the rate of favorable functional outcomes between patients who received IA-tPA vs those who did not (59.8% vs 66.1%; p = 0.27), 90-day home time was 77 (69-83) vs 66 (60-81) days, p = 0.26. There was no difference in the rate of sICH (2.2% vs 2.3%; P = 0.99), and mortality (15% vs 8.3%; P = 0.06). IA-tPA resulted in a significant improvement in TICI scores from 33.3% to 62.9% and was 3.4 times more likely to improve reperfusion status.ConclusionIA-tPA following thrombectomy with TICI score $\geq$ 2A appeared to be safe and improved the final TICI score; however, this angiographic improvement did not translate into functional outcomes.

Keywords: Ischemic stroke; TICI; endovascular thrombectomy; intraarterial thrombolysis; large vessel occlusion.