Our aim was to investigate the effect of intravenous tissue plasminogen activator (IV-tPA) on clinical outcomes in those treated for internal carotid artery (ICA) occlusions.

IV-tPA remains part of the guidelines for acute ischemic stroke treatment, yet ICA occlusions are known to be poorly responsive to IV-tPA. It is still unknown whether bridging thrombolysis is beneficial in such cases.

Data from 1367 consecutive stroke cases treated with endovascular thrombectomy (EVT) from 2012-2019 were prospectively collected from a single center. A total of 165 patients were found to have isolated, carotid terminus, and tandem ICA occlusions, who were treated within 4.5 hours of last seen well. Univariate and multivariate logistic regression were used to assess the relationship between tPA administration and clinical outcome.

Of 165 patients treated for ICA occlusions, 50% (n=82) received tPA. There were no differences between the groups with respect to age, NIHSS, time to treatment and ASPECTS score. Fifty-three percent (53%) had tandem ICA-MCA occlusions. Rate of recanalization (TICI2b) and symptomatic ICH did not significantly differ between the two groups. Regression analysis demonstrated no effect of tPA on modified Rankin Score (mRS) at 90 days and overall mortality. Factors significantly associated with reduced mortality included lower age, lower NIHSS, and better rate of recanalization.

There was no significant difference in clinical outcomes in those receiving bridging thrombolysis vs. direct thrombectomy for carotid artery occlusions.  For centers with optimal door-to-puncture times, bypassing IV-tPA may expedite recanalization times and potentially yield more favorable outcomes. Larger studies are warranted to further elucidate this question.