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IV Thrombolysis Before Thrombectomy Improves Recanalization in Extended Window

This target trial emulation offers real-world evidence that skipping intravenous thrombolysis before thrombectomy in the 4.5–24 hour window fails non-inferiority and reduces successful recanalization in perfusion-selected stroke.
alteplaseintravenous thrombolysismechanical thrombectomylarge vessel occlusionacute ischemic strokeextended time windowperfusion imagingtarget trial emulationtenecteplaseneuropharmacology Neurology / Neuropharmacology

Background Information

IVT pre-MT improves stroke recanalization success post-4.5 hours.

Determining whether direct mechanical thrombectomy (MT) is non-inferior to combined intravenous thrombolysis (IVT) and MT in an extended time window is crucial for optimizing acute stroke treatment. Direct MT did not demonstrate non-inferiority to IVT + MT beyond 4.5 hours, with lower successful recanalization rates in the direct MT group (adjOR 0.38). Findings suggest that IVT prior to MT might improve recanalization success in extended windows. Limitations include potential biases inherent to emulated trial designs. IVT before MT enhances recanalization success in the extended treatment window.

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Authors: Nicolini E, Ciacciarelli A, Pracucci G, Saia V, Simonetti L, Zini A, Da Ros V, D'agostino F, Iacobucci M, De Michele M, Andrighetti M, Tassi R, Saletti A, Casetta I, Fainardi E, Pauciulo A, Caggiula M, Menozzi R, Pezzini A, Vallone S, Bigliardi G, Zimatore DS, Petruzzellis M, Comai A, Franchini E, Allegretti L, Tassinari T, Limbucci N, Nencini P, Carità G, Russo M, Filizzolo M, Mannino M, Ruggiero M, Longoni M, Boghi A, Naldi A, Bergui M, Bosco G, Pelle G, Alessiani M, Alberti M, Invernizzi P, Augelli R, Cappellari M, Lazzarotti GA, Giannini N, Konda D, Sallustio F, Mangiafico S, Toni D, IRETAS group

Citation: Nicolini E, Ciacciarelli A, Pracucci G, et al. Direct Thrombectomy vs. Combined Treatment With Intravenous Thrombolysis in the Extended Time Window: A Target Trial Emulation. European journal of neurology. 2026;33(7):e70682. doi:10.1111/ene.70682

Article Links: PubMed · Journal / DOI

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