Update of Intravenous Thrombolytic Therapy in Acute Ischemic Stroke

Upon acute ischemic stroke, rapid recanalization of the occluded cerebral vessel via intravenous thrombolytic therapy (IVT) is crucial to achieve good functional outcome. The time window of IVT with recombinant tissue plasminogen activator (rt-PA) has been extended from post-stroke 3 to 4.5 hours. In patients with cerebral penumbra identified using cerebral perfusion imaging, IVT is still beneficial within 4.5 to 9 hours after onset of stroke. For those without clear stroke onset time, DWI-FLAIR mismatch by brain MRI indicates hyperacute infarct and IVT is indicative. For patients with large cerebral vessel occlusion, endovascular thrombectomy (EVT) alone is likely non-inferior to bridging therapy (IVT followed by EVT) and this issue is still under investigation. Serial studies have provided the evidence of safety and risk of IVT in specific groups of patients, such as elderly, anticoagulant users, and those having cerebral microbleeds or seizure. Tenecteplase has higher fibrin selectivity than rt-PA and large clinical trials have demonstrated its great potential for stroke therapy. Future clinical trials are mandatory for therapeutic optimization of IVT, especially in bridging therapy, specific groups of patients, and new thrombolytic agents. Keywords: Acute Ischemic Stroke, Cerebral Infarction, Recombinant Tissue Plasminogen Activator, Tenecteplase, Thrombolytic Therapy.