What are the options for thrombolytic therapy in acute management of stroke?

Updated: Sep 08, 2017
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

The Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) trial suggested that there might be benefit of administering IV t-PA within 3-6 hours of stroke onset in patients with small ischemic cores on diffusion-weighted magnetic resonance imaging (MRI) and larger perfusion abnormalities (large ischemic penumbras). [7]

The Desmoteplase In Acute Ischemic Stroke (DIAS) trial sought to show the benefit of administering desmoteplase in patients within 3-9 hours of onset of acute stroke with a significant mismatch (>20%) between perfusion abnormalities and ischemic core on diffusion-weighted MRI [8] .  Larger randomized trials of desmoteplase were negative. [9]

Muchada et al performed a study on 581 consecutive patients treated with alteplase to identify the impact of time-to-treatment according to stroke severity on functional outcome in patients with acute ischemic stroke. They found that the window for favorable outcome was 120 minutes or less for moderate strokes, but time-to-treatment seemed unrelated to functional outcome in mild and severe stroke. [10]

In a study of 285 patients who received intravenous recombinant tissue-type plasminogen activator, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%; 5.6% developed symptomatic intracerebral hemorrhages; 43.3% achieved good functional outcome; and 22.2% died within 90 days. According to the authors, adjusted comparisons by subgroups (age ≤ or >80 yr; onset-to-groin puncture ≤ or >6 hr; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization) systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome), and multivariate analyses confirmed the independent protective effect of revascularization. [11]

A study by Jovin et al showed successful endovascular therapy beyond 8 hours from time last seen well in patients selected for treatment based on MRI or CT perfusion imaging. Revascularization was successful in about 73% of patients. [12]

Advanced neuroimaging with diffusion and perfusion imaging may then serve an important role in identifying potentially salvageable tissue at risk and guiding clinical decision making regarding therapy. [8, 13, 14, 15, 16]

The iScore may also be used in patients with an acute ischemic stroke to predict clinical response and risk of hemorrhagic complications following IV thrombolytic therapy. [17]


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