Intravenous thrombolysis for acute ischemic stroke: why not?

Area of Science:

• Neurology
• Cardiovascular Medicine
• Emergency Medicine

Background:

• Intravenous thrombolysis (IVT) with recombinant tissue-plasminogen activator (rt-PA) is a cornerstone therapy for acute ischemic stroke (AIS).
• Challenges remain in patient selection, particularly for those with comorbidities or potential contraindications.
• Evolving evidence guides expanded use in specific patient populations and timeframes.

Purpose of the Study:

• To review the safety and efficacy of IVT (rt-PA) in AIS patients with comorbidities and contraindications.
• To highlight recent advancements in IVT for wake-up strokes and extended time windows.
• To summarize current evidence on systemic reperfusion therapy in acute ischemic stroke.

Main Methods:

• Systematic review of available evidence.
• Analysis of recent randomized trials and clinical experience.
• Focus on neuroimaging criteria for patient selection.

Main Results:

• IVT with rt-PA does not increase the risk of symptomatic intracerebral hemorrhage (sICH) in patients with stroke mimics, increasing age, or dual antiplatelet pretreatment.
• Advanced neuroimaging allows for expanded IVT time windows (4.5-9 hours) in wake-up stroke patients and those presenting later with specific imaging criteria.
• IVT remains a highly effective reperfusion therapy with 25 years of clinical use.

Conclusions:

• IVT with rt-PA is a safe and effective treatment for AIS, even in patients with certain comorbidities.
• Advanced neuroimaging facilitates expanded treatment windows, improving outcomes for more AIS patients.
• Ongoing efforts aim to simplify indications and overcome contraindications for broader IVT application.