Our objective was to compare rates of distal embolization in subjects who received IV alteplase (tPA) or IV Tenecteplase (TNK) followed by EVT.

The use of IV thrombolytics and concomitant intra-arterial therapy (IAT) in large artery occlusion (LVO) has become standard of care in acute ischemic strokes. Distal embolization may limit the efficacy of revascularization with IAT. Distal embolization may occur spontaneously or secondary to IV thrombolytics

Electronic medical records of subjects with acute ischemic stroke secondary to MCA occlusion who received TNK or tPA and underwent IAT therapy were reviewed. Digital subtraction images were reviewed to evaluate for distal embolization prior to revascularization. To confirm distal embolization, pre-procedure CT angiogram or CT head hyperdense sign were reviewed. Z score for 2 population proportions was used to compare rates of distal embolization in tPA and TNK subjects. Social Science Statistics was used for data analysis.

From June 2020 to May 2021, 29 subjects received IV thrombolytics (tPA n= 12; TNK n=17 ) followed by IAT. Five subjects were excluded from the TNK group with tandem and/or ICA occlusion. Twelve patients in each group with MCA occlusions (M1 or proximal M2 occlusions were compared). Difference in distal embolization rates had a trend towards statistical significance (z=-1.2649; p=0.10383).

The exclusion of tandem and/or ICA occlusions due to small sample size was a significant limitation of the study that affects generalizability to the strokes secondary to LVO. The trend towards statistical significance in higher distal embolization rates in subjects receiving TNK warrants larger, prospective studies to validate results.