Thrombolysis for acute ischaemic stroke: development and update

Thrombolytic therapy is a cornerstone in managing acute ischaemic stroke, marking significant advancements in treatment. Various generations of thrombolytics play crucial roles in different strategies, including intravenous thrombolysis, bridging therapy and thrombolysis beyond the conventional time window. The continuous development of thrombolytics has brought notable improvements. Compared to first-generation urokinase, second-generation alteplase and third-generation tenecteplase offer significant pharmacological advantages, such as enhanced fibrin specificity and longer half-lives. Tenecteplase demonstrates non-inferiority to alteplase regarding efficacy and safety, with the added benefit of a more convenient administration method. Ongoing trials continue to reveal additional evidence. Furthermore, other thrombolytic agents, including reteplase and non-immunogenic recombinant staphylokinase, are gaining increasing interest in the medical community. This review examines the structural characteristics, pharmacological properties, efficacy and safety profiles of these thrombolytic drugs. It also provides a detailed analysis of the performance of thrombolytic therapy in different acute ischaemic stroke patient subgroups, aiming to trace the evolution of these treatments and compare their effectiveness in acute ischaemic stroke. The goal is to offer a scientific basis for clinical practices and future development of thrombolytic therapies.