When would you consider intra-arterial thrombolysis for acute ischemic stroke?

The prior answer brings up several valid scenarios where IA thrombolysis may be applicable. I can offer some nuanced perspective based on current practice.

Device technology has advanced significantly since the landmark EVT trials of 2015. Today, EVT is increasingly feasible in distal-segment occlusions (M3, A2/A3, P2/P3), particularly when the patient’s deficits are significant and the operator feels technically confident. Beyond that range, the clinical burden is often lower and may not justify intervention.

Partially occlusive thrombi present a unique challenge, and in my experience, management depends heavily on location and flow dynamics. The more proximal the thrombus, the greater my caution. For example, a partially occlusive clot in...

Mechanical thrombectomy is considered first line over intra-arterial tPA now. I would consider IA tPA for the following scenarios:

1. The clot can’t be reached for mechanical thrombectomy, but a microcatheter can be placed for IA tPA.
2. If there is a partially occlusive clot that you don’t want to dislodge, so placement of a microcatheter proximal to give IA tPA might make sense.
3. After obtaining TICI 2b flow and still having a distal occlusion. There are now 3 clinical trials this year showing patients do better when IA tPA or TNK is given after TICI 2b or even TICI 3 flow is obtained. This should now become part of standard practice.

It is wonderful how vascular neurology continues to evolve. I'm not sure there is another situation in neurology where dead brain tissue can be restored (well, at least some of it).