Since the landmark clinical trials in 2015, mechanical thrombectomy (MT) has become the gold standard management approach for acute ischemic strokes due to large vessel occlusion. Despite the superior treatment effect and small potential harm of endovascular therapy, the stroke community continue to look for ways to improve treatment, as less than one-third of patients achieve complete reperfusion following MT. In particular, the role of bridging intravenous thrombolysis (IVT) to improve thrombectomy outcomes has been heavily investigated. Numerous large scale, randomized, clinical trials have aimed to elucidate whether IVT provides any additional benefit beyond what MT is capable of alone. However, most of these studies have failed to prove non-inferiority of direct MT and the debate is unresolved.

Beyond IVT, there is a renewed interest in intra-arterial thrombolysis (IAT) to optimize MT. IAT was chiefly studied as a primary therapy before the era of newer generation MT devices, but current investigations are looking at whether or not adjunctive intra-arterial alteplase after MT improves reperfusion outcomes, with promising early data starting to emerge.

In this podcast, stroke experts discuss the latest updates in recanalization therapy in acute ischemic stroke, highlighting the major debates that have the potential to change clinical practice. Both the value of bridging IVT and the assessment of intra-arterial thrombolysis after endovascular therapy to improve restoration of microcirculation are discussed.