Intra-arterial Thrombolysis or Stent Placement During Endovascular Treatment for Acute Ischemic Stroke Leads to the Highest Recanalization Rate: Results of a Multicenter Retrospective Study BACKGROUND: Reperfusion therapy for acute ischemic stroke (AIS) is rapidly evolving, with the development of multiple endovascular modalities that can be used alone or in combination. OBJECTIVE: To determine which pharmacologic or mechanical modality may be associated with increased rates of recanalization. METHODS: A cohort of 1122 patients with AIS involving the anterior circulation treated at 13 stroke centers underwent intra-arterial (IA) therapy within 8 hours of symptom onset. Demographic information, admission National Institutes of Health Stroke Scale (NIHSS), mechanical and pharmacologic treatments used, recanalization grade, and hemorrhagic complications were recorded. RESULTS: The mean age was 67 6 16 years and the median NIHSS was 17. The sites of arterial occlusion before treatment were M1 middle cerebral artery (MCA) in 561 (50%) patients, carotid terminus in 214 (19%) patients, M2 MCA in 171 (15%) patients, tandem occlusions in 141 (13%) patients, and isolated extracranial internal carotid artery occlusion in 35 (3%) patients. Therapeutic interventions included multimodal therapy in 584 (52%) patients, pharmacologic therapy only in 264 (24%) patients, and mechanical therapy only in 274 (24%) patients. Patients treated with multimodal therapy had a significantly higher Thrombolysis in Myocardial Infarction 2 or 3 recanalization rate (435 patients [74%]) compared with pharmacologic therapy only (160 patients, [61%]) or mechanical only therapy (173 patients [63%]), P , .001. In binary logistic regression modeling, independent predictors of Thrombolysis in Myocardial Infarction 2 or 3 recanalization were use of IA thrombolytic OR 1.58 (1.21-2.08), P , .001 and stent deployment 1.91 (1.23-2.96), P , .001. CONCLUSION: Multimodal therapy has significantly higher recanalization rates com- pared with pharmacologic or mechanical therapy. Among the individual treatment modalities, stent deployment or IA thrombolytics increase the chance of recanalization. KEY WORDS: Acute stroke, Endovascular stroke, Intra-arterial thrombolysis, Stent Neurosurgery 68:1618–1623, 2011 DOI: 10.1227/NEU.0b013e31820f156c www.neurosurgery-online.com O cclusion of a large intracranial cerebral artery is one of the major causes of acute ischemic stroke (AIS), often resulting in severe neurological morbidity, and effective early recanalization of these arteries has been dem- onstrated to correlate with favorable clinical outcomes. 1,2 Endovascular therapies used to achieve revascularization for AIS vary based on Rishi Gupta, MD* Ashis H. Tayal, MD§ Elad I. Levy, MD{ Esteban Cheng-Ching, MD‡ Ansaar Rai, MDk David S. Liebeskind, MD# Albert J. Yoo, MD** Daniel P. Hsu, MD‡‡ Marilyn M. Rymer, MD§§ Osama O. Zaidat, MD{{ Ridwan Lin, MDkk Sabareesh K. Natarajan, MD, MS{ Raul G. Nogueira, MD* Ashish Nanda, MD‡‡ Melissa Tian, RN§ Qing Hao, MD, PhD# Alex Abou-Chebl, MD## Junaid S. Kalia, MD{{ Thanh N. Nguyen, MD*** Michael Chen, MD‡‡‡ Tudor G. Jovin, MDkk *Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia; ‡The Cleveland Clinic Foundation, Cleveland, Ohio; §Allegheny General Hospital, Pittsburgh, Pennsylvania; {SUNY Buffalo, Buffalo, New York; kUniversity of West Virginia, Morgantown, West Virginia; #for the UCLA Revascularization Investigators and UCLA Stroke Investigators, University of California Los Angeles, Los Angeles, California; **Massachusetts General Hospital, Boston, Massachusetts; ‡‡University Hospitals, Cleveland, Ohio; §§Saint Luke’s Brain and Stroke Institute, Kansas City, Missouri; {{Medical College of Wisconsin, Milwaukee, Wisconsin; kkStroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; ##University of Louisville Medical Center, Louisville, Kentucky; ***Boston University School of Medicine, Boston, Massachusetts; ‡‡‡Rush University Medical Center, Chicago, Illinois Correspondence: Rishi Gupta, MD, 49 Jesse Hill Jr Drive, SE, Emory University School of Medicine, Faculty Office Building, #393, Atlanta, GA 30303. E-mail: rishi.gupta@emory.edu. Rishi Gupta and Ashis H. Tayal contributed equally to this work. Received, June 16, 2010. Accepted, November 18, 2010. Copyright ª 2011 by the Congress of Neurological Surgeons ABBREVIATIONS: AIS, acute ischemic stroke; HI, hemorrhagic infarction; IA, intra-arterial; ICH, in- tracerebral hemorrhage; MCA, middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; PH, parenchymal hematoma; rt-PA, recombi- nant tissue plasminogen activator; sICHs, symp- tomatic intracerebral hemorrhages; t-PA, tissue plasminogen activator 1618 | VOLUME 68 | NUMBER 6 | JUNE 2011 www.neurosurgery-online.com RESEARCH—HUMAN—CLINICAL STUDIES TOPIC Research—Human—Clinical Studies Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.