ABS 048: Evaluating the Impact of tPA vs. TNK and Thrombectomy Passes on Mechanical Thrombectomy Outcomes and Hemorrhage Risk

Riya Kar ¹, David Miller ²

¹ University of Florida
² Mayo Clinic

The Van Wickle Journal (2026) Volume 2, ABS048

Introduction: Ischemic stroke affects approximately 795,000 individuals each year in the United States, with large vessel occlusion (LVO) accounting for a significant portion of cases. Mechanical thrombectomy (MT) is a widely used treatment for LVO strokes and is often performed with intravenous thrombolytics (IVT), such as tissue plasminogen activator (tPA) or, more recently, Tenecteplase (TNK). Combined IVT and MT has been shown to be safe and effective in patients treated within 4.5 to 9 hours of symptom onset.
MT can be performed using aspiration, stent retrievers, or a combination of both techniques. While MT has significantly improved stroke outcomes, concerns remain regarding post-procedural hemorrhage, especially in cases requiring multiple device passes.

Methods: This retrospective study investigated the relationship between thrombectomy pass number and patient outcomes in individuals undergoing MT for LVO stroke. Outcomes were assessed using changes in Modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores before and after the procedure.
The study also examined whether the transition from tPA to TNK after 2021 affected patient outcomes, based on emerging evidence supporting TNK use in stroke treatment.

Results: The findings showed that performing more than four thrombectomy passes was associated with a significantly increased risk of post-procedural hemorrhage. Patients who underwent more than four passes also demonstrated a marked decline in postoperative mRS scores, suggesting poorer functional recovery. Intra-arterial tPA was also highly associated with post-procedural hemorrhage. Additionally, anticoagulant use, antiplatelet use, and higher doses of intra-procedural heparin injection were associated with increased hemorrhage risk after thrombectomy. Slight differences were observed in mRS and NIHSS outcomes between patients who received tPA and TNK; however, these differences were not statistically significant.

Discussion: These findings suggest that both procedural and medication-related factors may contribute to post-procedural hemorrhage after mechanical thrombectomy. More than four thrombectomy passes were associated with increased hemorrhage risk and poorer functional recovery, supporting consideration of a procedural pass limit. Intra-arterial tPA, anticoagulant use, antiplatelet use, and higher doses of intra-procedural heparin were also highly associated with hemorrhage, highlighting the need to carefully assess bleeding risk during treatment. Although slight differences were observed between tPA and TNK groups, they were not statistically significant, suggesting thrombolytic choice alone may not strongly affect outcomes in this cohort.