Intravenous Thrombolysis in Distal Medium Middle Cerebral Artery Occlusion Patients with Unsuccessful Mechanical Reperfusion

Hamza Adel Salim; Benjamin Pulli; Vivek Yedavalli; Dhairya Lakhani; Orabi Hajjeh; Basel Musmar; Nimer Adeeb; Fathi Milhem; Davide Simonato; Yan-Lin Li; Muhammed Amir Essibayi; Nils Henninger; Sri Hari Sundararajan; Anna Luisa Kühn; Jane Khalife; Sherief Ghozy; Luca Scarcia; Leonard L Yeo; Benjamin Y Q Tan; Robert W Regenhardt; Aymeric Rouchaud; Jens Fiehler; Sunil Sheth; Ajit S Puri; Christian Dyzmann; Marco Colasurdo; Leonardo Renieri; João Pedro Filipe; Pablo Harker; Răzvan Alexandru Radu; Mohamad Abdalkader; Piers Klein; Takahiro Ota; Ashkan Mowla; Kareem El Naamani; Pascal Jabbour; Arundhati Biswas; Frédéric Clarençon; James E Siegler; Thanh N Nguyen; Ricardo Varela; Amanda Baker; David Altschul; Nestor R Gonzalez; Markus A Möhlenbruch; Vincent Costalat; Benjamin Gory; Christian Paul Stracke; Constantin Hecker; Gaultier Marnat; Hamza Shaikh; Christoph J Griessenauer; David S Liebeskind; Alessandro Pedicelli; Andrea M Alexandre; Tobias D Faizy; Illario Tancredi; Erwah Kalsoum; Boris Lubicz; Vitor Mendes Pereira; Aman B Patel; Maurizio Fuschi; Max Wintermark; Jeremy J Heit; Adrien Guenego; Adam A Dmytriw; MAD MT Investigators

doi:10.1007/s00062-025-01583-8

Intravenous Thrombolysis in Distal Medium Middle Cerebral Artery Occlusion Patients with Unsuccessful Mechanical Reperfusion

Clin Neuroradiol. 2025 Nov 25. doi: 10.1007/s00062-025-01583-8. Online ahead of print.

Authors

Hamza Adel Salim^{1

2

3}, Benjamin Pulli⁴, Vivek Yedavalli⁵, Dhairya Lakhani^{5

6}, Orabi Hajjeh⁷, Basel Musmar⁸, Nimer Adeeb⁹, Fathi Milhem⁷, Davide Simonato¹⁰, Yan-Lin Li¹⁰, Muhammed Amir Essibayi¹¹, Nils Henninger¹², Sri Hari Sundararajan¹³, Anna Luisa Kühn¹⁴, Jane Khalife¹⁵, Sherief Ghozy¹⁶, Luca Scarcia¹⁷, Leonard L Yeo¹⁸, Benjamin Y Q Tan^{18

19}, Robert W Regenhardt⁷, Aymeric Rouchaud²⁰, Jens Fiehler²¹, Sunil Sheth²², Ajit S Puri¹⁴, Christian Dyzmann²³, Marco Colasurdo²⁴, Leonardo Renieri²⁵, João Pedro Filipe²⁶, Pablo Harker²⁷, Răzvan Alexandru Radu²⁸, Mohamad Abdalkader²⁹, Piers Klein²⁹, Takahiro Ota³⁰, Ashkan Mowla³¹, Kareem El Naamani⁸, Pascal Jabbour⁸, Arundhati Biswas³², Frédéric Clarençon³³, James E Siegler¹⁵, Thanh N Nguyen²⁹, Ricardo Varela³⁴, Amanda Baker¹¹, David Altschul¹¹, Nestor R Gonzalez³⁵, Markus A Möhlenbruch³⁶, Vincent Costalat²⁸, Benjamin Gory^{37

38}, Christian Paul Stracke³⁹, Constantin Hecker⁴⁰, Gaultier Marnat⁴¹, Hamza Shaikh¹⁵, Christoph J Griessenauer⁴⁰, David S Liebeskind⁴², Alessandro Pedicelli⁴³, Andrea M Alexandre⁴³, Tobias D Faizy⁴⁴, Illario Tancredi⁴⁵, Erwah Kalsoum¹⁷, Boris Lubicz⁴⁶, Vitor Mendes Pereira⁴⁷, Aman B Patel⁷, Maurizio Fuschi¹⁰, Max Wintermark⁴⁸, Jeremy J Heit⁴, Adrien Guenego⁴⁶, Adam A Dmytriw^{7

47}; MAD MT Investigators

Collaborators

MAD MT Investigators:
Abdelaziz Amllay, Achala Vagal, Adrien Ter Schiphorst, Ajith J Thomas, Anil Gopinathan, Anne Dusart, Carolina Capirossi, Charbel Mounayer, Charlotte Weyland, Cheng-Yang Hsieh, Christopher J Stapleton, Erwah Kalsoum, Flavio Bellante, Géraud Forestier, Hamza Shaikh, Hugo H Cuellar-Saenz, Iacopo Valente, Igor Sibon, James D Rabinov, Jérôme Berge, Jessica Jesser, Juan Carlos Martinez-Gutierrez, Kevin Premat, Lina Chervak, Lukas Meyer, Mahmoud Elhorany, Miguel Quintero-Consuegra, Mohammad Ali Aziz-Sultan, Monika Killer-Oberpfalzer, Peter T Kan, Priyank Khandelwal, Ramanathan Kadirvel, Robert Fahed, Sergio Salazar-Marioni, Shogo Dofuku, Simona Nedelcu, Stavropoula I Tjoumakaris, Suzana Saleme, Xavier Barreau, Yasmin Aziz

Affiliations

¹ Department of Neuroradiology, MD Anderson Medical Center, 77030, Houston, TX, USA. Hamza.sleeem@gmail.com.
² Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA. Hamza.sleeem@gmail.com.
³ Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, 26505, Morgantown, WV, USA. Hamza.sleeem@gmail.com.
⁴ Department of Interventional Neuroradiology, Stanford Medical Center, Stanford Palo Alto, CA, USA.
⁵ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
⁶ Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, 26505, Morgantown, WV, USA.
⁷ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁸ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁹ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA.
¹⁰ Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, University of Oxford, Oxford, UK.
¹¹ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
¹² Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
¹³ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
¹⁴ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁵ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹⁶ Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), University of Oxford, Oxford, UK.
¹⁷ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹⁸ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
¹⁹ Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.
²⁰ Neuroradiology Department, Dupuytren, Université de Limoges, University Hospital of Limoges, XLIM CNRS, UMR 7252, Limoges, France.
²¹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²² Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²³ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²⁴ Department of Interventional Radiology, Oregon Health and Science University, 97239, Portland, OR, USA.
²⁵ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁶ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁷ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁸ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁹ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
³⁰ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
³¹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), North State St, Suite 3300, 1200, Los Angeles, CA, USA.
³² Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³³ Department of Neuroradiology, Pitié-Salpêtrière Hospital, GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³⁴ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁵ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA.
³⁶ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁷ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁸ INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France.
³⁹ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁰ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.
⁴¹ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
⁴² UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA.
⁴³ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Roma, Italy.
⁴⁴ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Münster, Germany.
⁴⁵ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁶ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.
⁴⁷ Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada.
⁴⁸ Department of Neuroradiology, MD Anderson Medical Center, 77030, Houston, TX, USA.

PMID: 41291271
DOI: 10.1007/s00062-025-01583-8

Abstract

Background: The efficacy and safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT) for distal, medium vessel occlusions (DMVO) is not well established. This study investigates whether IVT impacts outcomes in DMVO patients, particularly in those with unsuccessful or partial recanalization after MT.

Methods: We conducted a retrospective, multicenter study using data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry. The study population included AIS patients with DMVO in the M2, M3, and M4 segments of the MCA, treated with or without IVT followed by MT and a final modified Thrombolysis in Cerebral Infarction (mTICI) score of 0, 1, or 2a. The primary outcome was functional independence, assessed by the 90-day modified Rankin Scale (mRS) of 0-1 or 0-2.

Results: The study comprised 210 patients with final mTICI 0 to 2a, with 130 undergoing MT alone and 80 receiving IVT followed by MT. Logistic regression analysis revealed no significant differences in clinical outcomes between groups. The odds ratios (ORs) for achieving a 90-day mRS of 0-1 and 0-2 were 1.55 (95% CI 0.62 to 3.87; p = 0.34) and 1.55 (95% CI 0.72 to 3.37; p = 0.26), respectively. The odds of symptomatic intracerebral hemorrhage (sICH) were similar between groups (OR 0.64, 95% CI 0.28 to 1.47; p = 0.29), as were the odds of intracranial hemorrhage (ICH) of any type (OR 1.39, 95% CI 0.71 to 2.73; p = 0.34).

Conclusions: In AIS patients with DMVO and unsuccessful or partial recanalization after MT, IVT did not significantly improve clinical outcomes. Additionally, IVT did not increase the risk of hemorrhagic complications. These findings suggest that while IVT preceding MT is safe in this context, it may not improve outcomes for patients with unsuccessful MT.

Keywords: Acute Ischemic Stroke; Distal Medium Vessel Occlusion; Intravenous Thrombolysis; Mechanical Thrombectomy; Middle Cerebral Artery; Modified Rankin Scale.