Utility of a rescue endovascular therapy for the treatment of major strokes refractory to full-dose intravenous thrombolysis

Objective: Large artery occlusion (LAO) in patients with major stroke predicts poor revascularization by intravenous thrombolysis (IVT) and more likely results in a poor outcome. We focused on the effects of intra- arterial thrombolysis (IAT) and endovascular mechanical recanalization (EMR) as rescue therapies in major strokes refractory to IVT. Methods: A retrospective analysis of 87 patients (National Institutes of Health Stroke Scale >20), who did not respond to full-dose IVT due to LAO, was performed based on their endovascular therapy status. IAT was performed as an intraclot infusion of alteplase, and EMR was provided by the Solitaire device (TM) (Covidien, Dubin, Ireland). The recanalization and 3-month outcome rates after IAT/EMR were correlated with a group of patients who were scheduled to receive endovascular treatment but who underwent only IVT. Results: We achieved successful recanalization by IAT and EMR in 68.7% and 76.1% of patients, respectively. Despite no significant differences in mortality between IAT and EMR, a trend towards better outcomes after IAT and a statistically significant increase for outcome-modified Rankin scale (mRS) 0-3 (45.7%) and mRS 0-2 (34.9%) after EMR was noted when compared with IVT. The degree of recanalization did not correlate with the functional results except for the good-moderate outcome after successful recanalization by EMR. Conclusion: EMR by the Solitaire device is a safe and beneficial method for the rescue treatment of patients with major stroke whose neurological status does not improve and who fail to recanalize the LAO after a 1-h full dose of IVT. Advances in knowledge: The article verifies efficiency of the Solitaire device in major strokes.