Intravenous Thrombolysis for Acute Ischemic Stroke

James C. Grotta, MD, FAAN Cerebrovascular Disease p. 425-442 April 2023, Vol.29, No.2 doi: 10.1212/CON.0000000000001207
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OBJECTIVE This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the “time is brain” versus “tissue clock” approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions.

LATEST DEVELOPMENTS The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the “time is brain” concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose “tissue clock” is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the “drip and ship” versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis.

ESSENTIAL POINTS IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.

Address correspondence to Dr James Grotta, Memorial Hermann Hospital - Life Flight, 18th Floor Sarofim—18.300.2, 6411 Fannin St, Houston, TX 77030, [email protected].

RELATIONSHIP DISCLOSURE: Dr Grotta has received personal compensation in the range of $5000 to $9999 for serving on a scientific advisory or data safety monitoring board for Haemonetics and Prolong Pharmaceuticals and in the range of $10,000 to $49,999 for serving as a consultant for Frazer Ltd and on a scientific advisory or data safety monitoring board for Acticor Biotech. The institution of Dr Grotta has received research support from Chiesi, CSL Behring, and Genentech. Dr Grotta has received publishing royalties from publications relating to health care.


© 2023 American Academy of Neurology.