WSC 2025 | The resurgence of intra-arterial therapy in stroke treatment

Definitely there is this comeback from intra-arterial therapy in a different use, let’s say. So in the early times, in the start of endovascular treatments, intra-arterial therapy was one of the first therapies to be assessed. But then the mechanical thrombectomy came and it had very high rates of efficacy in terms of clinical efficacy and recanalization and safety as well. So this was definitely the way to go. But now we are again considering the use of thrombolysis, intra-arterial thrombolysis, but now after the procedure for patients that have minor occlusion, so not very large vessels occluded, but still the reperfusion is not optimal. And there are even studies considering to use this in patients that have full reperfusion, meaning apparently a TICI 3, but maybe the neuroreflow phenomena or some micro, very distal or microvascular occlusions can contribute to persistent deficits and perfusion deficits. And so maybe these kind of agents can help on improving the outcome. So that has been tested in some studies. But still, and now the TECNO trial, which was a trial run mostly in Europe, has been finished. And we very much look forward to see the results. The TECNO trial, for example, was assessing exactly this. So TNK after incomplete reperfusion, TICI 2B/2C for large vessels, has a way to maybe improve recanalization outcomes. And so we hope to see the results soon. And also other studies are being conducted more or less with the same type of concept, but still different protocols. There are already meta-analyses and systematic reviews also collecting. Overall, it seems to be safe. There’s a trend towards efficacy in most of these studies, but the protocols are different. The agents, the dosages, and exactly the selection criteria of patients are not the same all across these studies. So definitely we need to have more evidence and then to understand exactly what are the patients that should receive this treatment, what should be the protocol, the dosage and the time until we can do the severity of the brain lesion. So there are a lot of issues that are not completely solved. So currently, in my opinion, we should include patients in these trials and wait for further evidence in order to proceed. But it seems very promising. And definitely, I think, in the future, the order by which we do the treatment, so thrombolysis, then thrombectomy, then intra-arterial thrombolysis, maybe other variations, is something that we should, as stroke researchers, invest time on understanding better what is the perfect sequence of intervention in order to improve outcomes.

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