ISC 2023 | Skipping thrombolysis in acute stroke with tandem occlusion

Thanh Nguyen, MD, Boston Medical Center, Boston University School of Medicine, Boston, MA, argues against the use of thrombolysis in patients with acute ischemic stroke who may undergo extracranial stenting. This dilemma was debated at ISC 2023, where Prof. Nguyen suggested that a personalized approach may be optimal. The summation of large volume of evidence has shown that the use of thrombectomy alone is not non-inferior to thrombectomy with prior intravenous thrombolysis (IVT) in non-transferred patients. However, the benefit of bridging IVT in tandem occlusion is debatable given the large clot burden and the potential need for periprocedural antiplatelet therapy in cases of acute carotid artery stenting. Emerging data suggests that antiplatelet therapy may be a better option in the setting of endovascular therapy for the tandem occlusion subset. No head-to-head comparative data for thrombolysis versus antiplatelet therapy is currently available but given the lack of evidence for the superiority of IVT over thrombectomy alone, and the potential need for stenting, further investigation in this setting is warranted. This interview took place during the International Stroke Conference (ISC) 2023 in Dallas, TX.

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