Author response: Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion

We thank Ganesh et al. for reading and commenting on our article on the comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) with direct MT in patients with emergent large vessel occlusion (ELVO).¹ We agree that IVT pretreatment can protect from infarct in new territory (INT), and may account for improved outcomes observed in the combination therapy (IVT + MT) group. Data on INT were not collected in our cohort. However, INT should be evaluated as one of the outcomes variables in future MT trials. We are also in support of another point made by Ganesh et al. about the recanalization rates with IVT alone. According to a recently published meta-analysis, roughly 1 of 10 patients with ELVO achieve successful recanalization with IVT pretreatment alone, negating the need for additional endovascular reperfusion therapy.² Although this rate is low, pretreatment with IVT appears to be important. Finally, we followed the suggestion of Ganesh et al. and compared outcomes (safety and efficacy) between direct MT (dMT) and combination therapy in the subgroup of patients with intracranial ICA occlusions. We failed to document any differences in the safety and efficacy outcomes between the 2 groups, but the small number of patients with ICA occlusions (n = 29), corresponding to 9% of the total matched cohort, needs to be taken into account in the interpretation of this subgroup analysis.