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Intravenous alteplase versus rescue endovascular procedure in patients with proximal middle cerebral artery occlusion


  • Conflicts of interest: Drs. Strbian, Mustanoja, Pekkola, Putaala, Haapaniemi, Paananen, and Lappalainen report no disclosures. Dr. Kaste has received honoraria and his travel expenses have been covered for participating in the Steering Committee meetings of ECASS, ECASS-II, ECASS-III, DIAS, DIAS-2, and DIAS-4 trials, and as a consultant for: Boehringer-Ingelheim, PAION AG, Forest Research Laboratories, Inc., and H. Lundbeck A/S and as a speaker in educational meetings sponsored by Boehringer-Ingelheim (modest). Dr. Tatlisumak had research contract with Boehringer-Ingelheim, Sanofi Aventis, H. Lundbeck A/S, Mitsubishi Pharma, Schering Plough, Concentric Medical, PhotoThera, and BrainsGate (significant). He has received grant from Boehringer-Ingelheim (modest) and served on the scientific advisory board and as consultant for Boehringer-Ingelheim, Mitsubishi Pharma, BrainsGate (modest).



To compare outcome of ischaemic stroke patients undergoing rescue endovascular procedure for proximal middle cerebral artery occlusion with matched patients without endovascular procedure after unsuccessful intravenous thrombolysis.


Endovascularly treated patients with middle cerebral artery occlusion (n = 41) were matched by propensity score with similar patients treated by intravenous thrombolysis and having a considerable post-thrombolysis neurological deficit (n = 82). We compared their three-month outcome (modified Rankin Scale) and frequency of symptomatic intracerebral haemorrhage. For the endovascular group, we report onset-to-puncture time, onset-to-recanalization time, and recanalization rates.


In age, gender, time from onset, admission National Institutes of Health Stroke Scale, systolic and diastolic blood pressure, blood glucose, history of hypertension, diabetes mellitus, hyperlipidaemia, atrial fibrillation, and congestive heart failure, and in aetiology, the groups were similar. Endovascular group patients had a recanalization rate of 90%, and more often reached three-month modified Rankin Scale 0–2 (36·6% vs. 18·3%, P = 0·03). Mortality was equally common (19·5%) in both groups, and frequency of symptomatic intracerebral haemorrhage was 9·8% vs. 14·6% (P = 0·45). The endovascular group's median onset-to-puncture time was four-hours and six-minutes and onset-to-recanalization time was five-hours and 12 min. The latter time was more than one-hour longer in patients treated under general anaesthesia compared with patients treated under conscious sedation (median four-hours 50 min vs. five-hours 58 min; P < 0·01).


Rescue endovascular approach increases likelihood of recanalization and may improve functional outcome in acute ischaemic stroke patients with proximal middle cerebral artery occlusion who did not respond to intravenous thrombolysis.