Thrombolysis in acute ischaemic stroke: an update

Abstract

Stroke is a major cause of mortality and morbidity, and thrombolysis has served as a catalyst for major changes in the management of acute ischaemic stroke. Intravenous alteplase (recombinant tissue plasminogen activator) is the only approved thrombolytic agent at present indicated for acute ischaemic stoke. While the licensed time window extends to 3 h from symptom onset, recent data suggest that the trial window can be extended up to 4.5 h with overall benefit. Nonetheless, 'time is brain' and every effort must be made to reduce the time delay to thrombolysis. Intracranial haemorrhage is the major complication associated with thrombolysis, and key factors increasing risk of haemorrhage include increasing age, high blood pressure, diabetes and stroke severity. Currently, there is no direct evidence to support thrombolysis in patients >80 years of age, with a few case series indicating no overt harm. Identification of viable penumbra based on computed tomography/magnetic resonance imaging may allow future extension of the time window. Adjuvant transcranial Doppler ultrasound has the potential to improve reperfusion rates. While intra-arterial thrombolysis has been in vogue for a few decades, there is no clear advantage over intravenous thrombolysis. The evidence base for thrombolysis in specific situations (e.g. dissection, pregnancy) is inadequate, and individualized decisions are needed, with a clear indication to the patient/carer about the lack of direct evidence, and the riskbenefit balance. Patient-friendly information leaflets may facilitate the process of consent for thrombolysis. This article summarizes the recent advances in thrombolysis for acute ischaemic stroke. Key questions faced by clinicians during the decision-making process are answered based on the evidence available.

Management of hyper-acute Ischaemic Stroke: Current status, challenges and opportunities in Northern Sri Lanka

“…The pharmacological target for AIS treatment is to recover the ischeamic penumbra which is the reversibly injured brain tissue around the ischeamic core 12,18 . The dynamic changes in the penumbra region and infarct expansion occur in response to regional cerebral blood flow, pathophysiological environment and treatment; it imposes an earliest intervention in AIS which is well described as "time is brain" 13 .…”

“…Imaging technologies such MRI, CT, PET and SPECT can be used to identify the salvageable brain tissue. Among them, CT scan serves as the gold standard imaging technology to exclude the patients with contraindications before choosing patients to undergo IV rtPA treatment 14,18 . At the same time, diffusion-weighted image (DWI) is used to identify the reversibly injured tissue in the early hours after stroke while Perfusion Weighted Image (PWI) is to identify the area of benign oligemia 12,15 .…”

“…Relative contraindications 18 1. Advanced age (more than 80) According to the Canadian heart and Stroke foundation, stroke care unit is a specialized, geographically defined hospital unit, dedicated for the management of all stroke patients (Evidence Level A) accomplished with an interdisciplinary team 23 .…”

Aphasia and reperfusion therapies in hyper-acute settings: A scoping review

“…Reperfusion therapies target areas of hypo-perfusion, which are areas of reduced blood flow (Robinson, Zaheer, & Mistri, 2011). Hypo-perfusion causes hypoxia (reduced oxygenation) and temporary loss of function to an area of the brain.…”

“…Exclusion criteria for IV alteplase include: uncertainty about time of onset, hypertension, septic embolus, and recent use of blood thinning medication such as heparin. If used within the recommended guidelines, IV alteplase is associated with a significant net reduction in death and disability in those treated with IV alteplase compared with those treated with placebo (52.4% versus 45.2%, respectively; OR, 1.34; 95% CI, 1.02-1.76; p ¼ .04) despite a small but significant increase in the risk of intracerebral haemorrhage (ICH) (2.4% versus 0.2%, p ¼ .008) (Robinson et al, 2011).…”