Prolonged low-dose intravenous thrombolysis in early recurrent stroke

Treatment of acute ischemic stroke follows well-established guidelines and standards of care. However, the optimal management of ultra-early stroke recurrence remains unclear. We present outcomes of prolonged low-dose intravenous thrombolysis used as rescue therapy in this setting.

This multicenter retrospective study included consecutive patients who received prolonged low-dose intravenous thrombolysis (20 mg of alteplase administered continuously over 10 hours) for early recurrent ischemic stroke. Clinical status was assessed using the National Institutes of Health Stroke Scale (NIHSS) at the time of recurrence and the day after rescue therapy. Functional outcome was evaluated using the modified Rankin Scale (mRS) at 90 days. Safety was assessed based on the occurrence of complications, intracerebral hemorrhage (ICH), and symptomatic intracerebral hemorrhage (sICH), defined according to the SITS-MOST criteria.

A total of 65 patients were enrolled across four centers (52.3% male; mean age 70.9 ± 12.2 years). The median NIHSS score was 4 after the initial stroke, increased to 10 at the time of recurrence, and improved to 6 following rescue therapy. Neurological improvement was observed in 70.8% of patients. A favorable functional outcome (90-day mRS ≤ 2) was achieved in 61.5% of patients. The 90-day mortality rate was 12.3%. Intracerebral hemorrhage occurred in 9.2% of patients, and no cases of symptomatic intracerebral hemorrhage were observed.

Rescue therapy with prolonged low-dose intravenous thrombolysis appears to be an effective and safe alternative to therapeutic nihilism in patients with ultra-early recurrent ischemic stroke. Confirmation of these findings in a randomized controlled trial would be highly valuable.