Introduction: Although it is clear that failure to reperfuse large vessel occlusion following intravenous thrombolysis is associated with high rates of morbidity and mortality, subsequent ‘rescue’ neurointerventional techniques remain controversial.
Methods: We report a case series of 11 consecutive patients treated with mechanical thrombectomy for acute ischaemic stroke following failed intravenous (IV) thrombolysis from a single institution over a 12 month period. A major arterial occlusion was demonstrated on neuroimaging in all patients prior to IV thrombolysis, which was commenced in all patients within 4.5 hours of stroke onset. The MERCI retrieval device was deployed in all patients, with adjunctive low-dose intra-arterial thrombolytic where warranted. The NIH Stroke Scale (NIHSS) at presentation and at hospital discharge was used to assess baseline severity and outcome.
Results: The median patient age was 64 (range 44-87) and median admission NIHSS was 20 (range 16-24). Four strokes were caused by ICA occlusion,five by proximal MCA occlusion, and two by vertebrobasilar occlusion. The median time from stroke onset to reperfusion was 4 hours (range 3.45 to 6). Successful reperfusion was achieved in 9 patients. The median discharge NIHSS in this group was 5 (range 1-9). All nine patients were either discharged home or to rehabilitation. Both patients with unsuccessful reperfusion died of malignant cerebral oedema. Symptomatic intracerebral haemorrhage was not observed.
Conclusion: In this non-randomised cases series of patients with failed IV thrombolysis, mechanical thrombectomy was associated with a better-than-expected outcome. Definitive proof of this therapy depends on evaluation in prospective randomized trials.